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CAYLOHD 

PRiNTtO  IN  U    S    A 

3   1822  01189  2544 


V.l 


PORTFOLIO 


OF 


DERMOCHROMES 


BY 

PROFESSOR    JAOOBi 

Of  Freiburg^  im  Breisgau 

English  Adaptation  of  Text  of  the  1st  and  2d  Editions 

BY 

J.  J.  PRINGLE,  M.B.,  F.R.O.P. 

Physician  to  the  Department  for  Diseases  of  the  SKin  at  the 
■Middlesex  Hospital,  London 

Fourth  Edition,  Revised  and  Enlarged 

WITH  246  COLORED  AND  2  BLACK  AND  WHITE  FIGURES  ON  134 
PLATES  WITH   EXPLANATORY  TEXT 

Volume  I 


NEW      YORK 

REBMAN     COMPANY 

1123  Broadway 


All  Rights  Reserved 


Printed  in  America 


DEDICATED 

TO 

Geheimrath  professor  Albert  Neisser 

OF   BRESLAU 


Preface  to  the  English 
Edition. 

The  process  employed  in  the  production  of  the  illus- 
trations in  the  following  work  is  that  known  as 
CiTocHKOMY,  and  is  the  invention  of  Dr.  Albert  of 
Munich.  The  reproduction  of  colours  by  this  process 
is  believed  to  be  more  perfect  than  by  any  other 
hitherto  in  use,  and  is  obtained  almost  entirely  by 
mechanical  means  apart  from  manual  work. 

The  great  majority  of  the  illustrations  are  taken 
from  models  in  the  Breslau  Clinic,  executed  by  Herr 
Kroner,  and  are  reproduced  by  kind  permission  of 
Professor  Neisser,  to  whom  the  inception  of  the  work 
is  mainly  due,  and  to  whom  it  is  dedicated  by  his 
former  pupil  and  assistant.  Professor  Jacobi. 

Thanks  are  also  due  to  Professors  Lesser  and 
C.  Lassar  of  Berlin,  Dr.  Bayet  of  Brussels,  and  Dr. 
Henning  of  Vienna,  for  permission  to  make  use  of 
models  in  their  possession. 

Acknowledgment  must  also  be  made  of  the  services 
rendered  by  the  gentlemen  who  executed  the  various 
models  utilized — viz.,  Herr  Kroner  of  Breslau,  Herr 
Kolbow  and  Herr  Kasten  of  Berlin,  Mons.  Baretta 
and  Mons.  Tramond  of  Paris.  A  few  of  the  models 
have  also  been  made  by  Professor  Jacobi  himself  after 
the  method  devised  by  Mr.  Cathcart  of  Edinburgh. 

The  object  of  the  Atlas  is  not  to  illustrate  the  rarer 


forms  of  skin  disease,  but  to  furnish  to  medical  men, 
teachers  and  students  a  handy  and  comprehensive 
series  of  illustrations  of  the  skin  affections  most  fre- 
quently met  with  in  practice,  in  their  various  phases 
and  at  a  reasonable  price  within  the  reach  of  all. 

As  no  attempt  has  been  made  to  supplement  the 
necessary  systematic  treatises  on  diseases  of  the  skin, 
the  text  has  been  condensed  to  the  greatest  possible 
degree,  without,  however,  omitting  any  of  the  essential 
facts. 

J.  J.  P. 
London. 


Editor's  Preface  to  the 
Second  Edition. 

The  early  and  gratifying  demand  for  a  second  edition 
of  this  work  testifies  to  its  utility. 

Two  new  plates,  with  text,  have  been  added,  \\z. : 
Plate  XVIa,  Fig.  28a  {Scrofuloderma),  and  Fig.  29a 
{Tiiberculide) ;  also  Plate  LXXVni.,  Fig.  141a 
{Syphilis  circinata)  and  Fig.  142a  {Paronychia  syphi- 
litica). Both  plates  are  taken  from  models  in  the 
collection  of  Professor  Neisser,  to  whom  the  renewed 
thanks  of  the  Editor  are  gratefully  acknowledged. 

The  following  figures  have  been  substituted  for 
those  which  appeared  in  the  first  edition,  viz.: 
Plate  LIX.,  Fig.  109;  Plate  LXXI.,  Fig.  129;  and 
Plate  LXXXIL,  Fig.  149. 

It  is  hoped  that  these  additions  and  alterations  will 
enhance  the  value  of  the  atlas,  the  price  of  which  re- 
mains unchanged. 

J.  J.  Pringle. 

vi 


Preface  to  the  Supplement. 

The  publication  of  a  Supplement  to  Professor  Jacobi's 
work  has  been  prompted  principally  by  the  urgent 
request  of  numerous  professional  friends  to  fill  in 
certain  lacunae  in  the  existing  work,  so  as  to  render  it 
a  practically  complete  pictorial  Atlas  of  Diseases  of 
the  Skin. 

To  these  friends  Professor  Jacobi  desires  to  express 
his  indebtedness.  The  Supplement  contains  seventy- 
six  new  dermochromes,  many  of  which  depict  syphi- 
litic manifestations,  the  importance  of  which  is  uni- 
versally admitted.  But  several  non-syphilitic  diseases 
not  hitherto  illustrated  are  also  included,  some  of 
which— e.^.,  Darier's  disease.  Myiasis  linearis— are 
regarded  in  most  text-books  as  extreme  rarities.  This 
opinion  Professor  Jacobi  does  not  share,  and  the  trans- 
lator endorses  the  author's  view. 

Numerous  types  or  phases  of  common  skin  affec- 
tions not  delineated  in  the  work  have  also  been  added, 
and  cannot  fail  to  conduce  to  its  increased  practical 
utility  both  to  the  student  and  practitioner. 

Especial  thanks  must  again  be  expressed  to  Pro- 
fessor Neisser  of  Breslau,  who  has  placed  his  entire 
wealth  of  material  at  the  author's  disposal.  A  deep 
debt  of  gratitude  is  also  due  to  Professor  von  Berg- 
mann.  Professor  Lassar,  Dr.  Max  Joseph,  Dr.  Buschke, 
Dr.  Heubner,  and  Professor  Greef,  of  Berlin ;  to  Pro- 
fessor Schlossmann  and  Dr.  Werther  of  Dresden;  to 


Dr.  Henning  and  Professor  Finger  of  Vienna;  to 
Professor  Pospelow  of  Moscow;  and  to  Professors 
Fournier  and  Jullien  of  Paris,  all  of  whom  have  per- 
mitted models  in  their  possession  to  be  utilized.  Due 
recognition  must  also  be  acknowledged  to  the  kindly 
and  energetic  assistance  of  Professor  Jacobi's  former 
assistant,  Dr.  von  Linck,  and  to  Messrs.  Baretta, 
Jumelin,  Kolbow,  Kroner,  Kasten,  Fiweisky,  and 
Johnson,  who  are  responsible  for  the  models  from 
which  the  dermochromes  have  been  executed  under  the 
direct  and  special  supervision  of  Dr.  Albert  of  Munich, 
with  whom  rests  the  credit  of  first  devising  and  carry- 
ing out  the  method  of  delineation  employed  through- 
out the  work  with  such  brilliant  success  and  gratifying 
results. 

J.  J.  Pbingle. 

London,  1906. 


viu 


Preface  to  the  Third  Edition. 

In  this  edition  a  number  of  illustrations  are  entirely 
new,  others  have  been  more  perfected.  In  the  place  of 
some  of  the  pictures  contained  in  the  previous  editions 
which  were  not  quite  satisfactory,  better  illustrations 
have  been  substituted.  The  plates  of  the  supplement 
have  been  properly  classified  with  the  other  subjects, 
and  the  whole  atlas  now  contains  132  plates  with 
245  illustrations.  The  test  has  been  revised  and  such 
matter  as  refers  to  new  illustrations  has  been  added. 

I  wish  to  express  my  feelings  of  gratitude  to  all 
those  who  gave  me  such  splendid  aid  in  the  prepara- 
tion of  the  previous  editions  and  of  the  supplement, 
and  who  extended  their  kind  offices  to  me  whilst  pre- 
paring this  third  edition. 

I  wish  particularly  to  thank  my  I.  Assistant,  Dr. 
Lever,  for  his  active  co-operation;  also  Dr.  Henning 
and  Mr.  Kolbow,  who  made  most  of  the  models ;  also 
Dr.  E.  Albert  of  Munich,  who  made  the  cliches;  like- 
wise Messrs.  Greiner  &  Pfeiffer,  in  Stuttgart,  and 
Messrs.  Christoph  Reisser's  Sons,  in  Vienna,  who  did 
the  presswork  with  so  much  care.  Particular  thanks 
are  due  to  my  publishers,  who  have  brought  great  sac- 
rifices in  order  to  produce  this  new  issue  in  the  same 
superior  and  elegant  style  as  the  previous  editions. 

E.  Jacobi. 
Fkeibueg  I.  Br. 


iz 


Preface  to   Fourth   Edition. 

In  this  edition  several  figures  of  superior  quality  have 
been  substituted.  It  also  contains  four  new  figures  of 
an  interesting  character.  Two  of  these  belong  to  the 
article  on  Sporotrichosis  by  Dr.  de  Beurmann,  of 
Paris,  with  his  kind  permission. 

E.  Jacobi. 
Freiburg  i./Be. 


Erythema  Exsudativum 
Multiforme. 

Plates  I.,  II.,  Figs.  1,  2,  3,  4. 

Erytbema  multiforme  is  a  skin  disease  which 
occurs  as  part  of  a  general  infective  malady — es- 
pecially in  spring  and  antumn — in  which  macules, 
papules,  vesicles  or  bullae  develop  in  a  few  days  on 
typical  seats  of  predilection,  especially  on  the  backs  of 
the  hands  and  feet,  and  extensor  surfaces  of  the  fore- 
arms and  legs;  it  often  also  appears  on  the  face  and 
other  parts  of  the  body,  but  only  in  exceptionally 
severe  cases  on  the  palms  and  soles.  Thus,  macular 
and  papular  erythema  (Fig.  3)  occur,  becoming  an- 
nular or  gyrate  (Figs.  1,  2) — when  involution  of  the 
patches  takes  place  in  their  centre — or  vesicular  (Fig. 
4).    The  cause  is  unknown. 

The  colour  is  bright  red  in  the  most  infiltrated 
marginal  parts,  but  livid  in  the  centre,  which  is  fre- 
quently sunken,  especially  in  cases  of  old  standing 
and  on  the  lower  extremities.  The  disease  is  poly- 
morphous, as  different  degrees  of  exudation  may  be 
present  at  the  same  time.  If  ring-shaped  papules  or 
circles  of  vesicles  in  concentric  circles  are  present  the 
affection  is  called  Erythema  iris  or  Herpes  iris  (a  bad 
name).  As  the  disease  progresses  the  papules  soften 
and  pale  without  scaling,  vesicles  dry  up,  and,  if  no 
relapses   occur — as   they   are   apt  to   do — the  whole 

1 


Jacobi's  Dennochromes. 


Plate  I. 


No.   I.  2.   Erythema  multiforme. 


Jacobi's  Dermochromes. 


Plate  11. 


No.  3.  4.   Erythema  multiforme. 


process  runs  its  course  in  a  few  weeks.  Some  partici- 
pation of  the  joints  is  not  infrequently  observed; 
implication  of  internal  organs  cannot  as  a  rule  be  laid 
to  the  charge  of  the  erythema.  On  the  other  hand, 
toxic  erythemata  occur  in  internal  disorders,  which 
ought  not  to  be  identified  with  true  erythema 
multiforme. 

Dlag-nosis  can  be  easily  established  in  typical 
cases  from  the  acute  onset,  the  general  phenomena, 
the  absence  of  subjective  symptoms — apart  from  slight 
burning  sensations — and  the  recovery  without  desqua- 
mation. The  somewhat  similar  syphilide  is  different 
in  colour,  and  usually  occurs  in  different  localiza- 
tions ;  eczemas  weep  and  itch ;  the  occasionally  similar 
urticarial  eruptions  are  much  more  ephemeral.  Eing- 
worm,  which  may  also  occur  in  concentric  forms,  is 
scaly,  and  never  presents  the  same  typical  distribution. 

Prog^nosls  is  thoroughly  favourable. 

Treatment. — As  the  disease  is  a  general  one  and 
joint  affections  are  often  present,  salicylate  of  soda 
in  doses  of  30  to  60  grains  daily,  or  similar  prepara- 
tions, are  generally  prescribed.  When  there  is  much 
burning,  compresses  of  a  1  per  cent,  solution  of  acetate 
of  aluminium  may  be  locally  applied ;  if  blebs  form,  the 
alcohol  spray  may  be  recommended. 


Figs.  1,  2.  Models  in  Neisser's  Clinic  in  Breslau  (Kroner). 

Fig.  3.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 

Fig.  4.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner).  A 
repeatedly  recurrent  vesicular  eruption  in  a  tailor- 
ess,  twenty-five  years  of  age,  with  high  fever  and 
joint  symptoms. 


Jacobi's  Dermochromes. 


Plate  III. 


No.  5.  Erythema  nodosum. 


No.   6.   Purpura  haemorrhaqica. 


Erythema  Nodosum. 

Plate  III.,  Fig.  5. 

Occasionally  associated  with  Erythema  multiforme, 
but  generally  alone,  there  appear  nodules  as  large  as 
a  hazel-nut  or  walnut,  with  special  frequency  on  the 
fronts  of  the  legs,  but  sometimes  also  on  other  parts, 
accompanied  by  pains  and  swelling  of  the  joints,  which 
give  the  impression  of  a  bruise  {E.  contusiforme),  and 
disappear  in  two  or  three  weeks.  The  affection  is 
most  probably  of  infective  character.  The  colour, 
which  is  at  first  bright  red,  goes  gradually  through  the 
whole  grade  of  tints  which  occur  in  blood  pigment  un- 
dergoing absorption.  Complications  with  diseases  of 
internal  organs,  especially  endocarditis,  sometimes  oc- 
cur, as  well  as  haemorrhage  into  mucous  membranes. 

The  Diag'nosis  may  be  made  without  difficulty 
from  the  localization  and  colour  of  the  lesions.  Bruises 
seldom  appear  in  such  large  numbers  and  in  the  same 
position,  while  they  are  generally  accompanied  by 
epithelial  erosions.  Multiple  gummata  develop  insidi- 
ously, are  different  in  colour,  and  tend  to  necrose. 

The  Erythema  induratum  of  Bazin,  which  affects 
the  same  localization  is  an  eminently  chronic  disease. 

The  Prognosis  is  favourable  in  uncomplicated 
cases,  but  it  must  be  guarded  in  presence  of  endo- 
carditis. 

3 


The  Treatment  consists  of  rest  in  bed  and  the 
administration  of  salicylic  preparations. 


Fig.  5.  Model  in  Lesser's  Clinic  in  Berlin  (Kolbow).  Woman, 
thirty-six  years  old,  without  joint  symptoms,  treated 
as  an  out-patient. 


Jacobi's  Dermochronies. 


Plate  IV 


c 
b/. 


X 

CO 
c 


Purpura  Haemorrhagica. 

Plate  III.,  Fig.  6 ;  Plate  IV.,  Fig.  7. 

Under  the  name  of  Purpura  are  described  certain 
diseases,  probably  of  infective  nature,  in  which  haemor- 
rhages into  the  skin  of  varying  intensity  are  observed. 
Petechise,  ecchymoses  and  vibices  are  all  superficial 
haemorrhages,  characterized  by  their  bright  red  or 
dusky  colour,  not  disappearing  under  pressure  with 
the  finger  or  a  glass.  The  lower  extremities  of  young 
persons  are  the  most  frequent  seats  of  small  or  large 
hagmorrhages,  which  develop — generally  with  rheu- 
matic symptoms  and  rise  of  temperature — commonly 
about  the  knees,  and  especially  in  spring  and  autumn 
{Purpura  vel  Peliosis  rheumatica) .  The  number  of 
haemorrhages  is  often  enormously  increased  by  re- 
peated relapses  until,  after  several  weeks,  the  disease 
ceases  and  the  effused  blood  is  gradually  absorbed, 
undergoing  the  well-known  changes  of  colour. 

Some  forms  of  purpura,  such  as  Werlhof 's  disease 
and  scur^^,  in  which  the  internal  organs  and  mucous 
membranes  are  chiefly  involved,  differ  from  this  clin- 
ical picture,  and  are  serious  diseases,  whereas  simple 
purpura  rheumatica  is  a  perfectly  harmless  affection. 
The  epidermis  over  single  haemorrhages  may  be  raised 
in  form  of  bullfe.    (See  Fig.  7.) 

The  Diagnosis  can  be  easily  established  from  the 
symptoms  described. 

5 


The  Prognosis  of  simple  purpura  rheumatica  is 
favourable. 

The  Treatment  consists  of  rest  in  bed  with 
elevation  of  the  extremities,  and  the  administration 
of  haemostatic  remedies,  such  as  ergotin,  tincture  of 
iron,  etc. ;  salicylate  of  soda  in  doses  of  30  to  60  grains 
daily  may  be  given  on  the  ground  of  the  probable  in- 
fectious nature  of  the  disease. 

Fig.  6.  Model  in  the  Vienna  Clinic  (Henning).  The  subject 
of  the  illustration  was  suffering  from  jaundice.  A 
number  of  bullae  with  slightly  hsemorrhagic  margins 
are  present  in  addition  to  the  usual  purpuric  spots. 

Fig.  7.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 


J<icobi's  Dennochromes. 


Plate  V. 


a. 


o 
2 


be 


tn 

On 

d 


Herpes  Simplex. 

Plate  IV.,  Fig.  8 ;  Plate  V.,  Figs.  9  and  10. 

Herpes  simplex  is  the  commonest  of  the  herpetic 
group  of  skin  diseases,  i.e.  of  benign  affections  which 
begin  acutely  and  are  characterized  by  the  appearance 
of  grouped  vesicles  on  normal  or  slightly  inflamed 
skin,  and  which  exhibit  no  further  developments  but 
only  undergo  regressive  changes.  They  are  most 
frequently  localized  on  the  genitals  (Figs.  8  and  9)  or 
face  (Fig.  10).  Sometimes  with  sharp  febrile  symp- 
toms and  sometimes  without  them,  one  or  several 
groups  of  small  vesicles — with  watery  contents — ap- 
pear upon  the  lips  or  their  mucous  surface,  on  the  im- 
mediately surrounding  skin  or  about  the  nose.  These, 
after  a  short  existence,  dry  up  and  heal  without  leav- 
ing scars.  The  eruption  may  also  appear  on  the 
genitals,  in  men  on  the  prepuce  or  glans,  in  women  on 
the  vulva  and  clitoris.  Secondary  infection  or  me- 
chanical irritation  may  result  in  deeper  lesions,  so  that 
some  delay  may  occur  in  the  healing  process.  It  is 
specially  to  be  noted  that  relapses  are  extremely  com- 
mon and  that  the  seats  of  previously  existent  hard 
chancres  show  a  marked  predilection  for  herpetic  out- 
breaks, both  on  the  genitals  and  elsewhere.  In  some 
instances  direct  communication  from  person  to  person 
appears  to  be  not  improbable.  As  a  rule  there  are  no 
subjective  symptoms  except  a  little  burning. 

7 


The  Diagnosis  can  always  be  easily  made  on  the 
face.  On  the  genitals  the  differentiation  of  a  herpes 
which  has  been  badly  treated,  or  become  the  seat  of 
pus  infection,  from  a  soft  chancre  or  primary  syphilitic 
sore,  may  be  difficult  at  first,  but  the  course  of  the 
disease  soon  settles  the  point. 

The  first  point  in  Treatment  is  to  ward  off 
secondary  infection  and  to  bring  about  the  earliest 
possible,  undisturbed  desiccation  of  the  vesicles;  this 
can  be  done  by  means  of  powders,  ointments  or  pastes 
but  the  best  application  is  90-95  per  cent,  alcohol  with 
the  addition  of  some  carbolic  acid  (1  per  cent.),  re- 
sorcin,  thymol  (|  per  cent.)  or  salicylic  acid. 

Fig.  8.  Model  in  Saint  Louis  Hospital  in  Paris,  No.  1923 

(Baretta).    Fournier's  case. 
Figs.  9,  10.  Models  in  Neisser's  Clinic  in  Breslau  (Kroner). 


Jacobi's  Dermochromes. 


Plate  VI. 


No.   1 1.   Herpes  zoster. 


Herpes  Zoster.    Shingles. 

Plate  VI.,  Fig.  11;  Plate  VII.,  Fig.  12. 

Herpes  zoster  {Shingles,  Zona,  Ignis  sacer)  occurs 
as  an  acute  infective  disease,  the  cause  of  which  is  un- 
known; it  is  characterized  by  an  outbreak  of  vesicles 
arranged  in  groups  on  an  inflamed  base  and  following 
the  distribution  of  nerves  or  nerve  plexuses  (Fig.  11). 
The  disease  is  almost  always  unilateral  and  the 
eruption  is  generally  accompanied  by  neuralgic  pheno- 
mena and  swelling  of  the  corresponding  lymphatic 
glands.  The  vesicles  of  any  one  group  are  always  in 
the  same  phase  of  development,  but  separate  groups 
may  appear  either  simultaneously  or  consecutively. 
The  number  of  groups,  as  well  as  the  number  and  size 
of  the  elementary  vesicles,  vary  within  very  wide 
limits.  Sometimes  only  a  few  papular  groups  are 
present  or  there  may  be  blebs  as  big  as  cherries.  Sub- 
sequently the  blebs  dry  up  leaving  no  scar.  But  in 
a  certain  number  of  cases  the  base  of  the  vesicles  is 
haemorrhagic  or  gangrenous  (Fig.  12),  and  in  them 
very  characteristic,  grouped  scars  are  left,  sometimes 
with  pigmented  margins. 

Zoster  occurs  most  frequently  in  spring  and  autumn 
like  other  infective  diseases,  and  as  in  them  one  attack, 
as  a  rule,  confers  immunity  against  others  throughout 
life.  The  seat  of  disease  may  be  in  the  distribution  of 
the  trigeminal  nerve,  or  of  various  spinal  nerves  or 

9 


plexuses.  In  cases  where  death  has  taken  place  owing 
to  intercurrent  disease,  lesions  of  the  corresponding 
spinal  ganglia  have  generally  been  demonstrated;  but 
zoster  of  toxic  origin  also  occurs  e.g.  after  poisoning 
by  arsenic  or  carbonic  oxide,  and  it  may  result  from 
disease  of  the  nerve  trunks. 

Central  disease  of  the  brain  and  spinal  cord  may 
also  cause  zoster.  The  primary  lesion  is,  therefore,  al- 
ways to  be  sought  for  in  the  nervous  system.  Trans- 
gression of  the  middle  line  (which  sometimes  occurs) 
and  extension  to  the  distribution  of  neighbouring 
nerves  are  easily  explained  by  the  existence  of  nerve- 
anastomoses. 

The  Diagnosis  of  zoster  is  easily  established 
from  its  unilaterality,  its  typical  vesicles  and  the  con- 
comitant neuralgia. 

The  Prognosis  is  generally  favourable  but  must 
be  guarded  with  reference  to  the  accompanying 
neuralgia. 

The  Treatment,  in  view  of  the  infective  nature  of 
the  disease,  must  first  consist  of  the  administration  of 
salicylic  preparations.  The  pain  may  be  combated  by 
quinine,  phenacetin,  antipyrin  and  similar  remedies. 
The  best  form  of  local  treatment  consists  in  alcohol 
compresses,  under  which  healing  most  rapidly  occurs. 
If  there  is  extensive  gangrene,  hot  compresses  of  a 
solution  of  silicate  of  aluminium  or  weak  nitrate  of 
silver  may  be  used. 

Fig.  11.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 
Fig.  12.  Model  in  Leaser's  Clinic  in  Berlin  (Kolbow). 


10 


Jacobi's  Dermochromes. 


Plate  VII. 


t/5 
O 

'5! 


o 


O 

c 
c 


in 

o 

N 

O, 

u 

u 


o 

2; 


Dysidrosis. 

Cheiropompholyx. 

Plate  VII.,  Fig.  13. 

In  persons  who  sweat  freely  there  often  occur  in 
summer  small,  clear  vesicles  which  lie  deep  in  the 
epidermis,  especially  on  the  sides  of  the  fingers  and 
ioes,  on  the  palms  and  soles,  more  rarely  on  the  backs 
of  the  hands  and  feet.  They  are  mostly  localized 
round  the  excretory  sweat-ducts  and  are  accompanied 
by  few  or  no  inflammatory  phenomena  (Fig.  13). 
Larger  blebs  sometimes,  but  seldom  form,  the  contents 
of  which  become  cloudy.  The  vesicles  gradually  dry 
up  and  recovery  ensues,  accompanied  by  marked 
scaling.  The  disease  gives  rise  to  considerable  itching. 
A  transition  to  the  establishment  of  eczema  is  some- 
times observed. 

The  Diag'nosis  is  at  first  easily  made  on  the 
grounds  of  localization  of  dysidrosis  and  the  absence 
of  inflammatory  symptoms. 

Treatment  attains  only  moderately  favourable 
results.  The  hyperidrosis  and  itcliing  must  be  chiefly 
combated;  for  these  purposes  painting  with  alcoholic 
solutions  of  tar,  resorcin  or  liquor  carbonis  detergens 
is  useful,  but  relapses  occur  with  great  regularity. 

Fig.  13.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 

11 


Pemphigus. 

Plates  VIII.  and  IX.,  Figs.  14,  15,  and  16. 

The  name  Pemphigus  connotes  a  severe  skin- 
affection  of  unknown  cause,  in  which  a  bullous 
eruption  of  very  chronic  nature  ajjpears,  accompanied 
usually  by  febrile  phenomena.  We  do  not  consider 
infantile  pemphigus  {Pemphigus  neonatorum)  or 
Duhring's  disease  {Dermatitis  herpetiformis)  as  being 
real  forms  of  pemphigus.  Usually  two  forms  of 
chronic  pemphigus  vulgaris  are  recognized, — the  one 
benign,  the  other  malignant — but  they  cannot  be 
definitely  differentiated  from  one  another,  inasmuch 
as  the  latter  may  develop  from  the  former.  In  both 
forms  blebs  of  various  size  and  indiscriminate  distri- 
bution and  which  are  filled  with  clear  fluid,  occur  in 
crops,  arising  chiefly  from  healthy  skin,  either  with  or 
without  rise  of  temperature;  sometimes  an  erythema 
precedes  the  eruption.  More  rarely  the  contents  of  the 
blebs  are  haemorrhagic. 

The  course  of  pemphigus  is  usually  extremely 
chronic  and  after  the  disappearance  of  one  eruption 
intervals  of  months  or  years  may  occur  before  another 
attack  ensues.  The  mucous  membranes  may  also  be 
attacked  apart  from  the  skin,  in  which  case  the  bullae 
do  not  attain  their  full  development  but  the  raised 
epidermis  adheres  in  the  form  of  a  whitish,  circum- 
scribed membrane ;  however,  the  mucous  membrane  is 

12 


Jacobi's  Dermochromes. 


Plate  VIII. 


No.    14.   Pemphigus  vegetans. 


No.    15.    I'einphigus  vulgaris. 


Plate  IX. 


lacobi's  Derniochromes 


Xo.    1 6.   Pemphigus  foliaceus. 


usually  involved  only  in  severe  or  fatal  cases  in  which 
the  skin  is  also  implicated. 

In  the  group  of  pemphigus  diseases  Pemphigus 
foliaceus  and  Pemphigus  vegetans  occupy  a  special 
place.  Other  forms  such  as  P.  circinatus,  with  ringed 
grouping  of  the  vesicles,  P.  gyratus  and  P.  prurigino- 
sus  with  severe  itching  must  also  be  classified  with 
Pemphigus  vulgaris. 

P.  foliaceus  and  P.  vegetans  almost  always  end 
fatally;  in  the  former  (Fig.  16)  the  blebs  are  extremely 
flabby  and  flat,  their  contents  being  cloudy.  Often 
the  process  does  not  go  so  far  as  bleb  formation  but 
the  epidermis  peels  off  in  thin  lamellse  over  extensive 
areas.  No  normal  reproduction  of  the  epidermis  takes 
place,  so  that  after  removal  of  the  scales  a  weeping 
rete  Malpighii  is  exposed  or,  if  some  apparent  skinning 
over  take  place,  the  slightest  mechanical  injury  suf- 
fices to  expose  the  deep  layers  of  the  skin.  The  dis- 
ease is  accompanied  by  violent  itching  and  profound 
interference  with  general  nutrition  and,  after  a  pro- 
longed period,  death  ensues. 

Pemphigus  vegetans  as  a  rule  first  manifests  itself 
by  blebs,  on  the  seat  of  which  condylomatous  out- 
growths form,  especially  on  surfaces  of  skin  in  appo- 
sition, on  the  genitals  and  surrounding  parts  (Fig.  14), 
in  the  axillae  and  below  the  mammae;  in  these  places 
no  normal  keratinisation  occurs  but  a  dirty,  horribly 
foetid  discharge  accumulates.  The  disease  always  ter- 
minates fatally,  its  course  being  usually  interrupted 
by  many  protracted  intervals  of  passivity. 

The  Diagnosis  of  P.  AOilgaris  is  easy  in  typical 
cases  if  bullous  eruptions  only  appear.  If  erythe- 
matous prodromal  rashes  occur,  it  must  be  diagnosed 
from  erythema  multiforme  by  the  differences  in  locali- 
zation and  course.     In  its  early  stages  P.  vegetans 

13 


may  easily  be  mistaken  for  syphilis,  but  the  absence  of 
other  signs  of  syphilis  the  course  of  the  disease  and 
the  utter  inefficacy  of  antisyphilitic  treatment  will 
decide  the  matter.  The  diagnosis  of  P.  foliaceus 
causes  difficulty  in  many  cases,  especially  as  regards 
pityriasis  rubra ;  the  weeping,  moist  base  of  the  lesions 
and  the  occurrence  of  flabby  blebs  will,  however, 
decide  the  diagnosis,  as  they  do  not  occur  in  pityriasis 
rubra. 

The  Prognosis  in  pemphigus  must  be  very 
guarded,  as  the  differentiation  between  the  mild  and 
severe  forms  is  at  first  extremely  difficult  to  establish. 
In  every  case  of  definite  pemphigus  it  must  be  con- 
sidered dubious. 

No  efficient  Treatment  of  pemphigus  yet  exists. 
We  can  only  diminish  the  often  terrible  sufferings,  the 
itching,  and  the  frightful  pain  which  results  from  the 
separation  of  the  adherent  clothes  or  bandages  from 
the  ulcerated  skin  by  ointments,  powders  or  baths;  in 
extensive  cases  permanent  baths  are  the  best.  In- 
ternally arsenic,  strychnine  and  antipyrin  are  recom- 
mended, but  their  value  is  more  than  dubious. 


Fig.  14.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 
Fig.  15.  Model  in  Lassar's  Clinic  in  Berlin  (Kasten). 
Fig.  16.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 


14 


] acol)i's  Dennochrornes. 


Plate  X. 


No.    17.  Pemphigus  neonatorum. 


N 


o.    18.   Dermatitis  herpetiformis  (Duhring). 


^^ 


Pemphigus  Neonatorum. 

Plate  X.,  Fig.  17. 

Pemphigus  neonatorum  is  an  infective  disease  which 
almost  always  occurs  in  epidemics ;  it  attacks  especially- 
new-born,  but  occasionally  older,  children.  Vesicles 
and  blebs,  usually  flat  on  the  top,  appear  with  or  with- 
out fever  on  skin  which  may  be  normal  or  reddened, 
and  the  rete  Malpighii  soon  becomes  exposed  (Fig. 
17).  As  the  disease  progresses  relapses  may  occur; 
but,  on  the  other  hand,  it  may  rapidly  recover  after  a 
single  outbreak.  Complications  may  take  place,  due  to 
secondary  infections. 

The  £tiolog'y  is  not  accurately  determined;  the 
distribution  of  the  eruption  is  in  no  sense  character- 
istic. 

The  Differential  Diag'nosis  from  syphilitic 
pemphigus  of  the  newly  born  may  be  established  by 
the  localization  in  the  latter  of  the  blebs  on  the  palms 
and  soles,  as  well  as  by  concomitant  evidences  of 
sj^hiUs. 

The  Prog^nosis  is  usually  favourable,  but  epi- 
demics of  unusual  severity  sometimes  occur. 

The  Treatment  consists  chiefly  of  protecting  the 
blebs  by  powders,  and  in  the  prevention  of  secondary 
infection  by  suitable  dressings,  or  by  baths  to  which 
antiseptics  have  been  added. 

Fig.  17.  Model  in  Lesser's  Clinic  in  Berlin  (Kolbow), 

15 


Dermatitis  Herpetiformis. 

(Duhring.) 

Plate  X.,  Fig.  18. 

The  disease  called  Dermatitis  herpetiformis,  so  dis- 
tinctly described  and  differentiated  by  Duhring,  is 
characterized  mainly  by  the  multiformity  of  its  mani- 
festations. Along  with  urticarial  wheals,  erythema 
and  papules  occur,  but  especially  blebs  of  various  size, 
accompanied  by  nervous  symptoms  and  extremely 
violent  itching.  The  process  may  be  arrested  in  any 
stage  of  its  evolution,  or  blebs  may  appear  without 
preliminary  lesions.  The  multiformity  of  the  morbid 
picture  is  increased  by  itching,  rubbing  and  secondary 
infections.  As  a  rule,  frequent  relapses  follow  one 
another,  and  the  disease  extends  over  an  extremely 
prolonged  period;  but,  despite  the  fact  that  the 
patients  become  greatly  exhausted  by  the  severe  sub- 
jective symptoms  and  the  frequent  relapses,  the  prog- 
nosis— in  contrast  with  that  of  pemphigus — may  be 
regarded  as  generally  favourable. 

The  EtiologT'  is  unknown;  but  a  neurosis  is  ac- 
cepted, in  many  quarters,  as  its  cause. 

The  Diagnosis  can,  as  a  rule,  be  established  only 
after  long  observation,  on  the  grounds  of  the  poly- 

16 


morphism,  the  intense  itching,  the  repeated  relapses, 
and  the  benign  course  of  the  disease. 

Treatment  can  only  be  symptomatic;  nervous 
phenomena  must  be  combated  by  nerve-tonics,  and  the 
sufferings  of  the  patient  alleviated  by  baths  and  the 
application  of  antipruritic  remedies.  Lotions  contain- 
ing alcohol,  sulphur  baths  and  tarry  preparations 
often  act  favourably;  as  may  the  internal  administra- 
tion of  arsenic  and  strychnine. 


Fig.  18.  Model  in  Saint  Louis  Hospital  in  Paris   (Baretta) 
No.  1352.    Tenneson's  case. 


IT 


Urticaria. 

Plates  XI.,  XII.,  XIII.,  Figs.  19,  20,  21,  22. 

Urticaria  is  characterized  by  the  appearance  of 
wheals — i.e.,  of  very  itchy,  flat  papules — either  white, 
bright  red  (Fig.  19),  or  more  rarely,  dark  red  (Fig. 
20)  or  livid  in  colour,  which  are  of  varying  size,  and 
appear  either  isolated,  or  in  groups,  or  confluent.  The 
wheals  may  disappear  as  quickly  as  they  appear  with- 
out, as  a  rule,  leaving  any  pigmentation;  serpiginous 
figures  may  be  formed  by  the  confluence  of  contiguous 
efflorescences.  The  extent  of  the  skin  affected  varies 
extraordinarily;  not  infrequently  the  greater  part  of 
the  body  surface  is  aifected  either  at  one  time,  or  by 
the  occurrence  of  successive  outbreaks  of  the  disease. 
In  many  persons  there  is  a  marked  tendency — either 
congenital  or  acquired,  as  the  result  of  previously  ex- 
isting skin  diseases — for  the  development  of  wheals 
on  any  part  of  the  skin  submitted  to  irritation ;  every 
scratch  mark  becomes  the  seat  of  an  urticarial  linear 
tract  (U.  factitia). 

In  children  small  wheal-like  papules,  intermixed 
with  true  wheals,  often  occur  in  frequently  repeated 
outbreaks;  these  papules  may  exhibit  a  vesicle  or 
blood-crust  on  their  surface  {Lichen  urticatus,  Stroph- 
ulus, Fig.  22),  constituting  an  affection  which  deserves 

18 


Jacobi's  Dennochromes. 


Plate  XI. 


No.   19.   Urticaria. 


Jacobi's  Dermochromes. 


Plate  XII. 


No.   20.   Urticaria  rubra. 


No.   21.   Urticaria  pigmentosa. 


special  consideration,  as  it  represents  in  many  in- 
stances the  forerunner  of  a  severe,  generally  incurable, 
disease  of  the  skin — viz.,  Prurigo. 

The  acute  circumscribed  oedemas — the  so-called 
giant  Urticaria — also  belong  to  the  urticarias,  in  which 
not  only  the  skin,  but  also  deeper  tissues  are  affected ; 
they  appear  and  disappear  suddenly;  the  disease  is 
rare,  and  generally  hereditary. 

The  very  rare  disease  Urticaria  pigmentosa,  which 
occurs  in  children,  must  also  be  mentioned.  The  ex- 
tremely persistent  wheals  leave  deep  pigmentary 
lesions,  which  exhibit  the  phenomena  of  factitious 
urticaria,  and,  as  a  rule,  persist  throughout  life. 
(Fig.  21.) 

Urticaria  may  be  evoked  by  external  irritants  in 
contact  with  the  skin  (insect  bites,  nettles,  etc.),  but 
the  eruption  does  not  remain  confined  to  the  part 
directly  affected ;  it  may  also  proceed  from  the  gastro- 
intestinal tract,  being  caused  by  certain  foods  in  dif- 
ferent individuals  (fish,  crab,  fruit,  especially  straw- 
berries), or  by  drugs.  As  a  rule  it  is  accompanied  by 
digestive  disturbances,  such  as  vomiting  and  diarrhoea 
{U.  ab  ingestis). 

Internal  disorders,  especially  such  as  determine 
changes  in  the  quality  of  the  blood  (leukaemia,  dia- 
betes), are  not  infrequently  accompanied  by  urticaria. 
Disorders  of  the  generative  organs  in  women  may  also 
cause  urticaria,  as  may  the  introduction  of  urethral 
bougies  in  men.  Pre,gnant  women  frequently  suffer 
from  factitious  urticaria  throughout  their  pregnancy, 
which  usually  disappers  after  delivery. 

In  addition  to  these  forms,  there  are  numerous  cases 
of  chronic  urticaria  in  which  no  cause  can  be  dis- 
covered, and  which  are  specially  rebellious  to  treat- 
ment. 


19 


The  Diag-nosis  of  urticaria  depends  upon  the 
typical,  evanescent  wheals,  and  on  the  occurrence  of 
itching.  Some  drug  eruptions  can  scarcely  be  differ- 
entiated from  urticaria. 


The  Prog^nosls  must  be  guarded  in  chronic 
urticaria  of  childhood  (?  Prurigo),  but  generally- 
speaking,  is  favourable,  exception  being  made  for 
chronic  nettlerash  in  which  the  general  condition 
may  be  very  unfavourably  influenced  by  itching  and 
insomnia. 


Treatment  can  only  be  successful  in  cases  where 
the  cause  can  be  traced  and  therefore  removed, 
particular  attention  being  paid  to  disorders  of  diges- 
tion and  general  diseases.  The  cure  of  any  affection 
of  the  female  generative  organs  will  often  bring  about 
recovery  in  cases  of  long-standing  urticaria.  If  no 
cause  can  be  discovered,  treatment  with  atropine, 
arsenic,  pilocarpine,  ergotin,  and  finally  with  chloride 
of  calcium,  may  be  tried.  In  such  cases  the  principal 
task  is  the  relief  of  the  sometimes  excruciating  itching. 
Opiates  must  only  be  used  with  the  greatest  caution 
as  hypnotics;  antipyrin  sometimes  stops  attacks  of 
irritation. 

With  regard  to  external  treatment,  it  must  be 
remembered  that  patients  react  in  widely  different 
fashion  to  heat  and  cold;  the  former  is  sometimes 
efficacious  in  the  form  of  warm  baths  or  douches,  but 
cold  water  applications  are  often  followed  by  better 
results.  Lotions  of  pure  alcohol,  menthol,  liquor  car- 
bonis  detergens  or  tar  may  be  tried,  as  well  as 
tumenol,  ichthyol  or  carbolic  acid.  Eecently  bromo- 
coll,  either  in  the  form  of  salve  or  lotion,  has  been 
used  successfully  as  an  antipruritic.    All  mechanical 

20 


Jacobi's  Dermochromes. 


Plate  XIII. 


No.   22.   Urticaria  chronica  infantum  (Slropliulus). 


irritation  of  the  skin,  by  rubbing  or  wearing  coarse 
underclothing,  must  be  avoided. 


Fig.  19.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner).  A 
man,  thirty  years  of  age,  suffering  from  chronic 
urticaria  since  the  age  of  one  year. 

Fig.  20.  Model  in  same  Clinic. 

Fig.  21.  Model  in  same  Clinic  (Kroner).  Boy,  two  years 
old,  suffering  also  from  tetany.  The  affection  dis- 
tributed over  the  entire  bodyj  skin  reflexes  exag- 
gerated; factitious  urticaria  over  the  entire  skin.. 

Fig.  22.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 


n 


Perniones.    Chilblains. 

Plate  XIV.,  Fig.  23. 

With  the  advent  of  winter,  especially  in  anaemic 
young  persons,  and  often  as  the  effect  of  only  slight 
degrees  of  cold,  livid  red  nodules  or  swellings  of 
doughy  consistence  occur  on  the  hands  and  feet  (Fig. 
23),  less  frequently  on  the  face  and  ears,  which  cause 
extreme  itching,  especially  when  the  patient  is  warm. 
Slight  mechanical  irritants  produce  bullous  elevations 
of  the  epidermis  over  these  lesions,  with  blood-stained, 
serous  contents,  from  which  ulcers  very  easily  form, 
which  are  atonic  and  heal  with  difficulty.  In  the 
majority  of  cases  hereditary  predisposition  can  be 
traced.  Spontaneous  recovery  ensues  with  the  advent 
of  warm  weather,  but  recurrences  are  almost  always  to 
be  expected. 

The  Diag-nosis  of  chilblains  is  easily  made,  based 
upon  their  seat  and  their  occurrence  with  the  onset  of 
cold  weather;  the  frequency  of  recurrences  is  to  be 
borne  in  mind  with  regard  to  Prognosis. 

Treatment  must,  in  the  first  instance,  be  directed 
towards  combating  the  anaemia,  which  is  almost  always 
present,  and  efforts  must  be  made  to  harden  the  skin. 
After  the  development  of  chilblains,  ulcers  may  be 


Jacobi's  Dermochromes. 


Plate  XIV. 


JD 

c 
0^ 


o 


C 

d 


induced  to  heal  by  wet  dressings  with  weak  (1  per 
cent.)  solutions  of  nitrate  of  silver,  or  with  balsam  of 
Peru  ointment.  Disturbances  of  circulation  may  be 
treated  by  massage,  hot  baths,  and  subsequent  wash- 
ing with  alcohol,  painting  with  tincture  of  iodine, 
collodion  or  traumaticin,  by  alcohol  sprays,  or  by  vig- 
orous inimction  of  a  10  per  cent,  chloride  of  lime 
ointment. 


Fig.  23.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner) . 


23 


Raynaud's  Disease. 

Plate  XTV.,  Fig.  24. 

In  Raynaud's  disease,  which  is  a  malady  due 
to  disturbed  innervation  of  central  origin  of  the  skin 
bloodvessels,  local  asphyxia  with  coldness  and  numb- 
ness occur  along  with  very  pale,  or  often  cyanotic,  dis- 
coloration of  the  skin  (Fig.  24).  For  years  the  process 
may  be  limited  to  these  associated  symptoms,  but 
necrosis  may  also  occur,  beginning  at  the  tips  of  the 
fingers  and  toes  {symmetrical  Gangrene). 

Treatment  consists  in  attempting  to  improve  the 
condition  of  the  circulation  by  baths,  massage,  etc., 
but  the  results  hitherto  obtained  are  not  encouraging. 


Fig.  24.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner).  Con- 
fer Transactions  of  the  Dermatological  Congress 
held  in  Breslau  in  1901. 


Jacobi's  Dermochroines. 


Plate  XV. 


en 
3 
in 
O 

•4-* 

H 
a; 


7) 
Oh 


PI 

CI 

O 


Jacobi's  Dermochromes. 


Plate  XVI. 


en 

3 
c/i 
O 


V 

■M 

>-. 

l-$ 

V 

en 

D 

a 

3 


00 


6 


Lupus  Erythematosus. 

Plates  XV.,  XVI.  and  XVII.,  Figs.  25,  26,  27,  28,  29. 

In  Lupus  erythematosus  the  skin  changes 
usually  begin  on  the  face  (Fig.  25),  on  the  ears  (Fig. 
26),  or  on  the  scalp  (Fig.  28),  more  rarely  on  the  ex- 
tremities (Fig.  27) ;  they  originate  as  indeterminate 
red  papules,  which  develop  by  peripheral  extension  to 
form  patches  with  margins  of  bright  red  colour,  cov- 
ered by  firmly  adlierent  scales.  These  become  greenish 
if  of  long  duration  and,  if  separated,  show  finger-like 
processes  on  their  under-surface  corresponding  to 
dilated  follicular  ducts.  At  the  margin  comedo-like 
plugs  are  also  often  present  which,  however,  are  drier 
and  not  so  fatty  as  true  comedones.  The  process  ex- 
tends peripherically  with  extraordinary  slowness,  while 
cicatricial  atrophic  spots,  often  traversed  by  telangiec- 
tases, develop  in  the  centre  without  the  occurrence  of 
ulceration.  A  bats-wing  configuration  frequently  re- 
sults from  the  favourite  localization  on  the  nose  and 
cheeks.  On  the  scalp  the  cicatricial  atrophy  gives  rise 
to  permanent  alopecia.  It  seldom  occurs  on  the  mucous 
membrane  (lips). 

The  redness  can  be  entirely  dispelled  by  pressure; 
but  on  pressure  with  a  lens  the  well-known  nodules  of 
Lupus  vulgaris,  from  which  this  disease  must  be  care- 
fully distinguished,  never  appear.  Sometimes  chilblain- 

25 


like  lesions  develop  on  the  fingers,  which  may  form 
rhagades  and  fissures,  and  cause  considerable  pain; 
apart  from  this,  the  disease  causes  little  or  no  subjec- 
tive symptoms.  Besides  this  form,  which  is  called 
Lupus  erythematosus  discoides,  there  also  occurs  an 
acute  form  {Lupus  erythematosus  disseminatus) ,  in 
which  numerous  efflorescences  occur  on  the  face  and 
body,  accompanied  by  violent  general  symptoms  and 
fever,  which  involute  after  a  short  existence  and  never 
extend  peripherically,  as  in  the  patchy  form,  but  heal 
with  the  formation  of  scars.  This  last  variety  may 
either  develop  from  discoid  Lupus  erythematosus,  or 
may  arise  spontaneously,  and  is  always  a  serious  dis- 
order. The  causes  of  Lupus  erythematosus  are  un- 
known, but  in  recent  years  an  attempt  has  been  made 
to  connect  the  disease  with  tuberculosis  by  attributing 
its  existence  to  the  presence  of  toxins  in  parts  of  the 
body  where  tubercle  bacilli  do  not  exist;  no  proof  of 
this  theory  has  yet  been  adduced.     (Fig.  29.) 

The  Diagnosis  of  Lupus  erythematosus  may  be 
based  on  its  seat,  the  discoid  shape  of  the  lesions,  the 
characteristic  scaling,  the  dilatation  of  follicles,  and 
the  central  atrophic  scarring.  The  differential  diag- 
nosis from  syphilis  and  Lupus  vulgaris  must  first  be 
established.  The  former  is  distinguished  by  the 
copious  amount  of  infiltration  and  the  coppery  or 
burgundy-like  colour  of  its  elements,  while  other  mani- 
festations of  syphilis  are  seldom  absent.  As  regards 
Lupus  vulgaris,  the  absence  of  nodules  and  ulcers  is 
especially  to  be  borne  in  mind.  Psoriasis  and  mycotic 
diseases  may  be  at  once  eliminated  by  the  absence  in 
them  of  atrophic  scars. 

The  Progriiosis  must  be  guarded,  as  treatment  is 
not  always  efficacious  in  the  discoid  forms;  the  dis- 

26 


Jacobi's  Dermoclnomc?. 


Plate  XVII. 


CL, 


o 


o 
2 


v: 

3 


c 


<u 
t/1 


c/i 
O 


c^ 


o 
2 


seminated  form  is   a   serious   ailment,   as   has   been 
already  remarked. 

Treatment. — As  Lupus  erythematosus  usually 
recovers  without  deep  destruction  of  tissue,  although 
in  no  definite  period  of  time,  treatment  must  be  adopted 
which  prevents  any  implication  of  the  deeper  parts. 
External  remedies  which  produce  congestion  and  ser- 
ous effusion  often  expedite  the  spontaneous  tendency 
to  recovery.  Vigorous  washing  with  soap,  superficial 
application  of  the  thermo-cautery,  painting  with  tinc- 
ture of  iodine,  and  the  inunction  of  sulphur  or  resorcin 
pastes,  are  often  eflScacious ;  but  after  each  application 
a  period  of  rest,  with  the  employment  of  some  indif- 
ferent salve  or  plaster  till  all  reaction  ceases,  must  be 
enjoined.  Covering  the  part  with  mercurial  plaster  is 
often  followed  by  good  results.  A  long-continued 
course  of  quinine,  with  the  simultaneous  application  of 
tincture  of  iodine  frequently  produces  excellent  effects, 
even  in  obstinate  cases.  In  the  vascular  form  good 
results  may  be  obtained  with  plasters  of  Empl.  salicyl.- 
saponat.  10%.  High  frequency  currents  are  also  rec- 
ommended. In  the  follicular  form  X-rays  are  indi- 
cated. 


Figs.  25,  26,  28.  Models  in  Neisser's  Clinic  in  Breslau 
(Kroner). 

Fig.  27.  Model  in  Saint  Louis  Hospital  in  Paris,  No.  1437 
(Baretta).  Vidal's  case.  Symmetrical  Lupus 
erythematosus  of  the  hands,  the  face  being  simi- 
larly affected. 

Fig.  29.  Model  in  Freiburg  Dermatological  Clinic  (Johnsen). 
The  superficial  invasion  of  the  skin  of  the  cheeks 
permits  the  recognition  of  the  existence  of  numer- 
ous small  circular  lesions,  especially  in  the  mar- 
ginal portions  of  the  disease.  Under  internal  treat- 
ment with  quinine  and  painting  with  iodine  the 
affection  was  soon  reduced  to  minimal  proportions. 


37 


Lupus  Pernio. 

Chilblain  Lupus. 

Plate  XVII.,  Fig.  30. 

Lupus  pernio  is  a  rare  disease,  the  relationships  of 
which  to  Lupus  vulgaris  and  Lupus  erythematosus  are 
not  yet  clearly  defined.  It  is  characterized  by  the 
development  of  large  cyanotic,  ill-defined  infiltrations 
and  swellings,  more  especially  on  the  uncovered  skin 
of  the  face,  ears,  and  hands.  Small  excoriations  and 
ulcers  may  form  in  some  spots,  which  heal  up  very 
slowly  after  scabbing,  leaving  scars.  The  malady, 
which  generally  occurs  in  ana?mic  persons,  may  recover 
spontaneously  even  after  lasting  for  years. 

The  Differential  Diag-nosis  must  be  espe- 
cially established  from  chilblains.  These  latter,  how- 
ever, are  smaller  in  size,  and  disappear  with  the  advent 
of  warm  weather. 

Treatment. — No  certain  method  of  curing  Lupus 
pernio  is  known.  It  is  advisable  to  combat  anaemia  with 
iron  and  arsenic.  For  the  ulcerative  forms  moist  dress- 
ings may  be  used ;  but  if  the  epidermis  is  intact,  warm 
baths,  massage,  and  mild  plasters  are  suitable. 


Fig.  30.  Model  in  Saint  Louis  Hospital  in  Paris,  No.  1694 
(Baretta).     Tenneson's  case. 


28 


I 


Jacobi's  Dermochromes. 


Plate  XVIII. 


I/) 

o 
o 

3 

> 


> 


a, 
6 


-ff,.--a 


n 


■■^ 


:.'.  M 


}<-■.;■■ 


C/5 


■r. 

a, 


o 


Jacobi's  Derinochromes. 


Plate  XIX. 


c 

V 


o 

c 

o 
U 


^0 

> 

71 

Oh 

3 


O 

2 


3 
> 

t/1 

3 


d 


Jacobi's  Dennochromes. 


Plate  XX. 


to 


a. 


d 
2 


oc 


t/) 

D 

a, 

a 

-J 


2 


J.icol)i's  Dermochronies. 


Plate  XXI. 


-2° 
> 


O 

Z 


E 

_o 

13 
'a, 


> 

-J 


The  course  of  Lupus  vulgaris  is  extremely  chronic; 
the  disease  usually  begins  in  early  childhood,  more 
rarely  at  more  advanced  periods  of  life.  It  spreads 
slowly,  or  gives  rise  to  fresh  deposits  round  about.  The 
general  health  is  often  little  or  not  at  all  impaired, 
although  persons  suffering  from  advanced  lupus  are 
more  liable  to  general  tubercular  infection  than  healthy 
individuals.  In  the  course  of  lupus  tubercular  infec- 
tion of  lymphatic  vessels  may  occur,  as  the  result  of 
which  "cold  abscesses"  may  form  at  various  points, 
which  may  break  externally,  and  from  this  results  so- 
called  scrophuloderma  without  lupus  (Gommes  scrofu- 
leux,  Fig.  32).  The  involvement  of  the  afferent  lymph 
channels  as  the  result  of  erysipelas — which  is  not  an 
uncommon  complication — leads  to  the  formation  of 
elephantiasic  growths  on  the  genitals  and  extremities 
(Fig.  40),  the  lupus  origin  of  which  can  only  with 
difficulty  be  established  after  the  healing  of  the  lupus. 
A  very  malignant  form  of  epithelioma  develops  in  some 
cases  on  the  top  of  lupus  of  many  years'  duration  (Fig. 
37) ;  more  rarely  a  benign  new  growth  of  epithelial 
origin  may  develop  (Cornu  cutaneum,  Fig.  34). 

Sometimes  lupus  exists  secondarily  to  tubercular 
diseases  of  other  tissues,  more  especially  to  old-stand- 
ing affections  of  bones  or  glandular  fistulse,  in  which 
case  the  lupus  nodules  are  generally  present  in  cica- 
trices in  the  immediate  neighbourhood  of  these  lesions. 

The  Diagnosis  of  Lupus  vulgaris  is  not  difficult 
if  typical  nodules  are  present,  especially  when  the  part 
is  examined  by  pressing  a  glass  or  lens  on  it,  the 
nodules  being  thereby  rendered  manifest  by  the  ex- 
pression of  the  hyperaemia  which  conceals  them.  The 
result  of  exploration  with  a  probe  confirms  the  diag- 
nosis. As  nodules  cannot  be  demonstrated  in  all  phases 
of  the  disease,  its  extremely  chronic  course  is  worthy 

31 


of  special  notice.  Syphilis  produces  much  more  ex- 
tensive and  deeper  lesions  in  a  much  shorter  time. 
Other  points  of  importance  are — the  onset  of  the  mal- 
ady generally  in  youth,  the  absence  of  pain  and  lastly, 
the  reaction  to  Koch's  original  tuberculin,  which  is 
an  absolutely  certain  criterion. 

The  differential  Diag>nosis  must  be  established 
from  Lupus  erythematosus  (absence  of  implication  of 
bone  and  of  lupus  ulceration),  from  Acne  rosacea 
(lumpy  swellings,  but  no  lupus  nodules),  from  Ring- 
worm (microscopical  demonstration  of  fungus,  no 
ulcers),  but  especially  from  Syphilis,  as  already  men- 
tioned. This  latter  point  is  not  always  easy,  but  the 
inefficacy  of  antisyphilitic  treatment,  the  special  ten- 
dency for  syphilis  to  attack  bones,  and  the  typical 
reaction  of  lupus  to  tuberculin,  generally  decide  the 
question. 

The  Prognosis  as  regards  life  is  favourable, 
apart  from  the  occurrence  of  general  tubercular  in- 
fection, but  as  regards  cure  it  is  absolutely  unfavour- 
able in  extensive  cases.  Permanently  successful  re- 
sults have  hitherto  been  attained  only  in  recent,  limited 
cases  suitable  for  excision.  We  have,  however,  in  late 
years  obtained,  by  the  use  of  Finsen's  light,  permanent 
cures  even  in  severe  cases  of  lupus  which  have  hitherto 
been  considered  of  the  most  dire  nature,  owing  to  the 
hideous  disfigurement  so  often  produced  by  them. 

The  results  of  Treatment  depend  in  the  first 
instance  on  early  diagnosis.  If  the  lupus  infiltration  is 
so  circumscribed  that  it  can  be  removed  in  toto  without 
excessive  loss  of  substance,  radical  extirpation  is  to  be 
recommended  just  as  if  one  were  dealing  with  a  malig- 

32 


Jacobi's  Dermochromes. 


Plate  XXII. 


No.  39.  Lupus  vulgaris  serpiginosus. 


jacobi's  Dermochronies. 


Plate  XXIII. 


No.  40.   Lupus  vulgaris  ;   Elephantiasis 
consecutiva. 


No.  41.    Lupus  vulgaris;    Mutilatio. 


nant  tumour;  the  loss  of  substance  must  be  remedied 
by  suture  or  by  grafting.  In  more  extensive  lupus,  or 
when  the  subcutaneous  tissue  and  lymphatic  vessels 
are  extensively  involved,  this  procedure  gives  less  cer- 
tain and  less  beautiful  results.  By  scraping,  scarifica- 
tion, galvano-caustic,  or  galvano-cautery,  or  by  hot- 
air  treatment  (which,  however,  often  causes  cheloid 
scars),  either  alone  or  combined  with  caustics,  appar- 
ently good  results  may  for  a  time  be  obtained,  but 
recurrences  almost  invariably  take  place.  The  best 
caustic  is  arsenic  in  the  form  of  arsenical  paste,  but  it 
cannot  well  be  employed  over  large  surfaces  on  account 
of  pain  and  intoxication;  the  same  remark  applies 
to  pyrogallol  in  ointments  from  2  to  10  per  cent,  in 
strength.  Both  remedies  have  a  selective  action — 
i.e.,  they  spare  the  sound  and  destroy  the  diseased 
tissue,  but  neither  protects  from  relapses.  Solid  nitrate 
of  silver,  especially  with  the  addition  of  nitrate  of 
potassium  to  harden  the  nitrate  stick,  is  of  service  for 
boring  into  nodules  covered  with  epithelium,  or  may, 
in  strong  solutions,  be  used  for  ulcers,  but  its  effects 
are  generally  too  superficial.  Chloride  of  zinc  and 
caustic  potash  are  deeply  penetrative  and  energetic 
remedies,  but  they  destroy  also  sound  tissue.  Lupus 
ulcers  may  heal  well  under  1  per  thousand  corrosive 
sublimate,  or  2  per  cent,  permanganate  of  potash  dress- 
ings, but  the  results  are  not  permanent. 

Lupus  of  mucous  membranes  can  be  advantageously 
destroyed  by  cauterization  with  lactic  acid,  or  by 
thermo-  or  galvano-  cautery.  The  injection  of  tuber- 
culin, or  of  tuberculin  and  resorcin,  cannot  effect  the 
cure  of  lupus. 

All  the  foregoing  methods  produce  definite  cure 
only  in  a  small  number  of  cases  and  after  very  pro- 
longed use.  Better  results  appear  sometimes  to  be 
attained  by  treatment  with  Rontgen  rays  until  scab- 


bing  is  produced;  but  this  method  has  not  hitherto 
been  generally  adopted,  on  account  of  its  very  pro- 
longed duration  and  the  sclerodermic  changes  in  the 
skin  which  sometimes  result  from  it. 

Undoubtedly  the  best  results  in  extensive  cases  of 
lupus,  both  from  the  cosmetic  and  actually  curative 
points  of  view,  have  been  obtained  by  Finsen's  treat- 
ment with  concentrated  sunlight,  or  by  strong  electric 
light  from  which  the  heat  rays  are  eliminated.  To 
judge  by  the  results  obtained  by  Finsen  himself,  the 
greater  number  of  cases,  even  of  protracted  duration, 
which  formerly  would  have  been  considered  incurable 
may,  by  this  means,  be  brought  to  a  really  perfect 
cure,  and  with  the  best  imaginable  cosmetic  results,  so 
that  the  possibility  of  completely  eradicating  lupus  is 
not  to  be  completely  rejected.  Unfortunately,  the 
general  adoption  of  the  Finsen  treatment  has  hitherto 
been  rendered  very  difficult  by  the  high  price  of  the 
installation,  the  expense  of  the  treatment,  and  by  its 
long  duration.  None  of  the  cheaper  apparatus  de- 
signed to  replace  Finsen's  original  apparatus  (Lortet 
and  Genoux,  Bang,  the  Dermo  lamp,  Foveau  and 
Trouvet)  have,  despite  the  great  expectations  founded 
upon  them,  succeeded  in  surely  effecting  the  cure 
of  lupus;  so  that  up  to  the  present  the  erection 
of  public  institutes  provided  with  Finsen's  original 
apparatus  must  be  considered  and  advocated  as  the 
most  potent  weapon  against  this  terrible  malady. 

General  recuperative  treatment  must  be  adopted  in 
lupus  as  in  tubercular  affections  of  internal  organs. 


Figs.   31,   32,   35,  42.    Models   in   Freiburg  Dermatological 

Clinic  (Jolinsen). 
Figs.    33    and    39.    Models    in    Neisser's    Clinic    in    Breslau 

(Kroner). 
Fig.  34.  Model  in  Saint  Louis  Hospital  in  Paris,  No.  1059 

(Baretta).    Guibout's  case. 

34 


Jacobi's  Dermochromes. 


Plate  XXIV. 


No.  42.   Lupus  vulgaris  mucosae  oris. 


No.  43.  Verruca  necrogenica. 


Fig.  38.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 

Figs.  36,  40,  41.  Models  in  Neisser's  Clinic  in  Breslau 
(Kroner). 

Fig.  37.  Model  in  Saint  Louis  Hospital  in  Paris  (Baretta). 
Besnier's  ease.  Male,  aged  fifty-one ;  disease  of 
twenty-two  years'  standing,  only  slightly  treated, 
and  especially  never  with  thermo-cautery. 


Verruca  Necrogenica. 

Post-mortem  Wart. 

Plate  XXIV.,  Fig.  43. 

Not  infrequently  there  are  present  on  the  hands  of 
anatomists,  pathologists  and  post-mortem  room  ser- 
vants peculiar  brown  or  grayish-black  hard  growths, 
with  reddened  and  somewhat  inflamed  surrounding 
tissue.  The  affection,  which  results  from  the  inocula- 
tion of  tubercle  bacilli,  is  generally  quite  benign  and 
superficial ;  only  seldom  can  its  transformation  into 
lupus  or  extension  into  deeper  tissues  (lymphatics,  ten- 
dons) be  observed.  Spontaneous  cure  frequently 
occurs. 

The  Differential  Diag-nosis  has  usually  only 
to  be  established  from  common  warts,  in  which  there 
is  no  surrounding  inflammatory  zone ;  their  surface  is 
also  generally  more  uniform  than  that  of  post-mortem 
warts. 

The  Prog-nosiS  is  almost  always  favourable. 

Treatment  must  be  chiefly  surgical.  In  very 
extensive  cases  the  question  of  destruction  by  Light 
treatment  may  be  worthy  of  consideration. 

Fig.  43.  Model  by  Professor  Jacobi  in  the  Freiburg  Clinic. 


36 


Scrophuloderma. 

Plate  XXV.,  Fig.  44. 

The  subcutaneous  lymphatics— and  especially  the 
lymphatic  glands— are  sometimes  infected  as  the  re- 
sult of  tuberculous  disease  of  the  skin,  bones  or  joints ; 
and,  in  consequence,  painless  semi-globular  nodules 
form,  either  isolated  or  arranged  in  lines,  which  differ 
in  size  and  vary  from  a  pale  reddish  to  a  livid  colour. 
These  become  attached  to  the  skin  from  beneath,  then 
gradually  soften  and  break  down,  discharging  a  thin, 
purulent  fluid.  The  walls  of  the  resulting  abscesses 
collapse  and  flat  ulcers  form,  which  secrete  a  slight 
amount  of  discharge  and  are  soon  covered  with  scabs. 
Their  walls  are  deeply  eroded ;  or  narrow  fistulae  result, 
in  the  neighbourhood  of  which  the  skin  is  extensively 
undermined.  Sometimes  spontaneous  healing  occurs, 
with  the  formation  of  irregular,  radiating  scars;  but 
in  other  cases  treatment  alone  effects  a  cure  of  this 
extremely  obstinate  disorder. 

The  Diag'nosis  is  usually  obvious  owing  to  the 
co-existence  of  other  scrophulo-tuberculous  lesions,  but 
sometimes  it  may  present  points  of  difficulty  in  differ- 
entiation from  syjihilitic  gummata.  The  hardness  of 
the  infiltration  and  moderate  degree  of  softening,  as 
well  as  the  formation  of  tyjiical,  crateriforra,  sharply- 
defined  ulcers  is  to  be  specially  noted.     Finally,  the 

37 


beneficial     results — or     inefficacy — of     anti-syphilitic 
treatment  settle  any  doubts. 

The  Prognosis  must  be  guarded. 

Treatment. — The  nodules  are  best  treated  by 
surgical  extirpation  extending  well  into  sound  tissue. 
If  extensive  softening  has  taken  place,  thorough 
scraping  and  subsequent  dressing  with  iodoform  may 
be  recommended. 

Fig.  44.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 


38 


Jacobi's  Derinochromes. 


Plate  XXV, 


No.  44.  Scrophuloderma. 


No.  45.    Tuberculide. 


Tuberculide. 

Plate  XXV.,  Fig.  45. 

The  justification  of  the  term  Tuberculide  as  applied 
to  the  majority  of  diseases  of  the  skin  supposed  to 
result  from  the  toxins  of  tuberculosis,  or  to  many 
so-called  "tuberculous  exanthemata,"  appears  to  be 
extremely  dubious.  Some  skin  affections,  however 
{e.g.,  Erythema  induratum  of  Bazin  and  Lichen 
scrophulosorum),  are  veritable  tuberculoses;  while  the 
condition  named  the  "acneiform"  or  "necrotic" 
Tuberculide  {Folliclis)  has  a  hardly  contestable  claim 
to  the  name  of  Tuberculide.  In  this  protean  disease 
sharply  defined  nodules  develop  in  the  subcutaneous 
tissue,  and  over  these  macules,  papules  or  vesicles 
form.  Either  absorption  or  superficial  necrotic 
changes  ensue,  resulting  in  loss  of  substance  and  the 
gradual  formation  of  sharply  defined  white  scars,  the 
surrounding  tissue  being  at  first  deeply  pigmented. 
The  seats  of  predilection  are  the  backs  of  the  hands, 
the  flexor  and  ulnar  sides  of  the  forearms,  and  the 
ears.  The  eruption  may,  however,  appear  on  other 
parts  of  the  body  and  generally  does  so  in  the  form 
of  crops  of  lesions  appearing  in  groups.  The  course 
of  the  disease  is  very  tedious.  Other  chronic  tubercu- 
lous lesions  generally  co-exist. 

The  Diag'nosis  in  characteristic  cases  is  based 

39 


on  the  typical  localization  and  evolution  of  the  lesions. 
In  others,  it  can  only  be  established  by  a  process  of 
exclusion  and  in  consideration  of  co-existent  tubercu- 
lous manifestations. 

Treatment  must  in  the  first  place  be  directed  to 
the  tuberculous  element  in  the  condition.  No  specific 
method  of  local  treatment  is  yet  known. 


Fig.  45.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 


40 


Jacobi's  Derniochromes. 


Plate  XXVI. 


N 

CO 


O 
en 

zs 
jr 
cu 
o 

u 
o 

£ 

-4-* 

D 
t3 


0) 


6 
2 


3 
I. 
O 

a 

a, 
o 


u 


d 
2 


r// 


Lichen  Scrophulosorum. 

Tuberculosis  Milio-papulosa 
Aggregate. 

Plate  XXVI.,  Fig.  46. 

On  the  trunk,  and  less  frequently  on  the  limbs  of 
persons  suffering  from  tuberculosis  of  the  skin,  bones 
or  glands,  there  develop  (usually  unnoticed  by  the 
patient)  numerous  yellow  or  yellowish-red,  acuminate, 
small  papules,  sometimes  in  groups,  at  other  times 
scattered  indiscriminately.  These  papules,  after  last- 
ing for  some  time,  develop  a  small  scale  on  their  sur- 
face, and  if  present  in  larger  numbers,  coalesce  to  form 
scaly,  rough,  yellowish-brown  patches  (Fig.  46).  The 
eruption,  which  generally  occurs  in  young  persons, 
causes  no  subjective  symptoms;  only  seldom  does  the 
transformation  of  the  papules  into  pustules  or  acnei- 
form  pimples  occur.  The  disease  is  undoubtedly  of 
tuberculous  nature,  as  shown  by  reaction  to  tuberculin, 
the  anatomical  structure  of  the  miliary  tubercles,  and 
the  discovery  of  bacilli  in  them;  but  it  is  caused  by 
bacilli  of  slight  virulence.  The  intensity  of  the  erup- 
tion varies  according  to  the  condition  of  the  under- 
lying tubercular  disease. 

The  Diag-nosis  can  be  determined  with  ease  on 
the  existence  of  the  typical  papules  and  the  eo-exist- 

41 


ence  of  a  tubercular  basis,  or  ultimately  on  the  occur- 
rence of  reaction  to  (the  original)  tuberculin. 

The  Differential  Diag-nosls  need  only  be 
established  from  the  small  papular  syphilide,  which 
can  be  eliminated  by  the  failure  of  antisyphilitic 
treatment. 

The  Prog'nosis  is  favourable. 

Treatment  must  first  be  directed  towards  com- 
bating the  original  tuberculosis,  and  may  be  assisted 
by  inunctions  of  cod-liver  oil,  or  preferably,  by  weak 
chrysarobin  ointment,  which  soon  brings  about  a  cure, 
without  leaving  any  traces. 


Fig.  46.  Model  in  Freiburg  Clinic   (Johnsen). 


42 


Erythema  Induratum 
Scrophulosorum. 

(Bazin). 

Plate  XXVI.,  Fig.  47. 

In  young  scrofulo-tubercular  subjects,  more  fre- 
quently in  the  female  than  in  the  male  sex,  there  are 
sometimes  present  on  the  legs  hard,  red  or  bluish-red, 
densely  infiltrated  nodules,  which  develop  unnoticed, 
as  they  cause  neither  pain  nor  itching ;  these  sometimes 
break  and  discharge  their  strikingly  yellow-coloured 
contents.  Either  after  or  without  rupture  the  nodules, 
which  are  of  extremely  long  and  persistent  duration, 
are  slowly  absorbed,  leaving  behind  deep  pigmenta- 
tion, while  at  the  same  time  new  lesions  may  develop. 
They  are  situated  in  the  true  skin  and  subcutaneous 
tissue;  their  margins  are  well  defined;  infiltrated  areas 
as  large  as  the  palm  of  the  hand  may  result  from  their 
extension  and  confluence.  There  is  an  undoubted  con- 
nection between  this  disease  (which  is  of  greater  fre- 
quency than  is  generally  recognised)  and  tuberculosis, 
but  the  existence  of  tubercle  bacilli  in  it  has  not  yet 
been  demonstrated.  Deeper  invasions  of  tissue  do  not 
occur. 

Treatment  must  first  be  directed  to  the  tuber- 

43 


eular  origin  of  the  disease.    Local  treatment  is  gen- 
erally unnecessary  and  futile. 


Fig.  47.  Model  in  Freiburg  Clinic  (Vogelbaclier). 


44 


[acobi's  Dennochromes. 


Plate  XXVIIA. 


3 
T3 


O 
o 


o 


d 
Z 


Sporotrichosis   of  Beurmann. 

Plate  XXVIIa;  Figs.  49o  and  496. 

(From  Ikonographia  Dermatologica — Rebman  Company, 
Neiv  York) 

Beurmann  and  his  associates  have  made  special 
studies  to  enable  them  to  more  fully  establish  and  de- 
fine the  changes  caused  in  the  skin  by  colonies  of  a 
certain  filary  fungus,  called  sporotriclius. 

They  have  found  two  distinct  types  of  sporotrichosis. 
In  the  first  form,  sporotrichosis  gummosa  dissemi- 
nata tuberculoides  (Fig.  49a),  multiple,  deep,  subcu- 
taneous nodules  develop  by  a  slow,  painless  process, 
which  gradually  affect  the  skin  by  nodulation.  They 
soften  in  the  centre  and  discharge,  through  a  narrow 
fistula,  on  pressure,  pus  which  at  first  is  tenacious,  but 
afterward  turns  into  a  serous  fluid  tinged  with  streaks 
of  blood.  The  central  depressed  orifice  is  encircled  by 
a  tough  infiltration  of  a  bluish-red  tinge.  There  is  no 
tendency  to  heal  spontaneously,  whilst  a  similarity  to 
scrophulous  gummata  exists;  glandular  swelling  is 
absent,  likewise  other  tuberculoid  manifestations. 

In  the  second  but  rarer  type  (Fig.  496),  a  painful 
ulcer  quickly  makes  its  appearance  without,  however, 
any  appreciable  rise  in  the  temperature.  The  centre 
of  this  ulcer  shows  a  marked  tendency  to  scar  forma- 
tion. The  irregular  but  sharply  defined  edges  are 
dotted  with  shaggy,  papillomatous  growths.  From 
this  primary  ulcer  lympathatic  cords  extend  with  nu- 


merous  gummatous  nodes  which  are  partially  movable 
and  partially  adherent  to  the  derma.  These  finally 
penetrate  the  skin  and  turn  into  verrucous  plaques 
somewhat  resembling  the  primary  lesion.  Freshly  de- 
veloped foci  look  more  like  acne  nodules  or  strongly 
simulate  the  plaques  of  Eczema  seborrhoicum. 

There  are  other,  but  rather  rare  types  of  Sporotri- 
chosis, such  as  the  lymphangitic  gummous,  classic 
form  described  by  Schenk-Hectoen,  and  also  that  men- 
tioned by  Dor  with  multiple  larger  abscesses. 

Both  types  of  Beurmann's  Sporotrichosis  show  a 
well-marked  similarity  to  certain  forms  of  tuberculosis, 
especially  to  Scrophuloderma  as  well  as  to  the  gummous 
syphilis.  The  manner  of  softening,  i.e.,  the  foundation 
of  narrow  central  fistulae  surrounded  by  a  broad,  indu- 
rated zone,  as  well  as  the  absence  of  other  tuberculoid 
manifestations,  are  the  noticeable  features  of  the  Spo- 
rotrichosis gummosa  disseminata.  In  the  second  form 
much  quicker  and  more  far-reaching  changes  may  be 
observed  than  is  the  case  in  tuberculosis  and  syphilis. 

The  Diagnosis  can  only  be  established  with  cer- 
tainty through  cultural  methods.  Nearly  all  culture 
media  (the  most  reliable  for  this  purpose  is  Sabour- 
aud's)  produce  from  implantations  of  cellular  tissue^ 
pus,  secretions  or  scales,  under  medium  or  body-tem- 
perature within  5-10  days,  small  white  or  brownish  cul- 
tures surrounded  by  a  flat  radiation  which  later  on  as- 
sumes a  brown  to  black  colour.  Under  the  microscope 
this  appears  as  long,  about  2  fj.  wide,  straight  or 
slightly  curved,  and  at  times  ramified  threads.  Ad- 
hering to  these  are  numerous  egg-shaped  spores  of 
various  magnitudes.  In  the  pus  itself,  as  also  in  the 
secretions  and  in  the  cellular  tissue,  it  is  difficult  to 
discover  these  spores  with  the  microscope.    Sporotri- 

446 


chosis  produces  similar  changes  in  animal  inoculation 
with  cultures,  whilst  with  the  pus  or  cellular  tissue  it- 
self no  results  are  obtained. 

Fro£rnosis  is  favourable. 

Proper  Treatment,  consisting  of  internal  and  ex- 
ternal applications  with  Iodine  preparations,  will  ef- 
fect a  sure,  though  at  times  slow,  cure.  The  alkali  com- 
pounds of  Iodine  meet  the  requirements  for  internal 
medication.  For  external  use  wet  bandages  with  Io- 
dine or  Iodide  of  potassium  and  kindred  lotions  are 
indicated. 


Figs.  49«,  495.  Models  in  the  St.  Louis  Hospital  in  Paris 
(Baretta).  No.  2531  and  2557.  Dr.  de  Beurmann's 
cases. 


44c 


Tuberculosis  Linguae. 
Tuberculosis  Nasi. 

Tuberculosis  of  Tongue  and  Nose. 

Plate  XXVII.,  Figs.  48  and  49. 

In  persons  who  suffer  from  tuberculosis  of  internal 
organs,  true  tuberculosis  of  the  skin  and  mucous  mem- 
brane, especially  at  their  points  of  junction,  is  observed 
much  less  frequently  than  ordinary  lupus.  But — gen- 
erally as  the  result  of  direct  infection  by  bacilli  in  the 
discharge — ulcers  may  form  which  are  round  or  irreg- 
ular in  shape,  painful,  and  extend  rapidly;  their  base 
is  granular,  bleeds  easily,  and  is  partly  covered  with 
sticky  discharge,  while  miliary  tubercular  nodules  may 
not  infrequently  be  identified  at  their  margins  (Fig. 
49).  On  mucous  membrane  the  margins  are,  as  a  rule, 
undermined  (Fig.  48).  Numerous  bacilli  are— in 
contradistinction  to  lupus— to  be  found  in  the  ulcers, 
which  have  also  a  much  slighter  tendency  to  heal,  ex- 
tend with  far  greater  rapidity,  but  seldom  attain  larger 
dimensions  than  in  lupus,  as  the  patients  die  sooner. 

The  Diagnosis  can  generally  be  established  with- 
out difficulty  on  the  grounds  of  their  localization,  char- 
acteristic appearance,  painfulness,   and   the   general 

46 


Jacobi's  Derniochronies. 


Plate  XXVII 


in 

O 


ON 

d 


V 

a 


(J 


-t 

6 


tubercular  symptoms.  It  may  be  confirmed  by  the 
discovery  of  bacilli.  The  differentiation  from  syphilis 
may  be  established  by  the  behaviour  of  the  lesions 
under  antisyphilitic  treatment. 

The  ProgTlOSis  is  unfavourable. 

Treatment  must  have  for  its  object  the  diminu- 
tion of  pain  by  dusting  with  orthoform,  anfesthesin, 
and  similar  remedies,  as  the  general  condition  of  the 
patient  usually  forbids  the  use  of  energetic  measures. 
Should  such,  however,  be  permissible,  attempts  may 
be  made  to  effect  a  cure  with  caustics,  "light  treat- 
ment," or  surgical  measures. 


Fig.  48.  Model  in  Saint  Louis  Hospital  in  Paris,  No.  1768 

(Baretta).     Tenneson's  case. 
Fig.  49.  Model  in  Saint  Louis  Hospital  in  Paris,  No.  2236 

(Baretta).    Hallopeau's  case. 


46 


Lepra.    Leprosy. 

Elephantiasis  Crsecorum. 

Plates  XXVIII-XXX.,  Figs.  50-55. 

Leprosy  is  a  general  infective  disease,  known  even 
in  very  ancient  times  as  a  contagious  malady,  which 
was  very  widely  distributed  till  the  Middle  Ages.  At 
the  time  of  the  Crusades,  however,  it  was  forced  into 
the  background  by  the  advance  and  extension  of 
syphilis,  and  now  its  occurrence  is  extraordinarily 
diminished,  so  that  it  exists  with  frequency  in  the 
tropics  only,  and  is  scattered  sporadically  over  Europe 
(Norway,  Russia,  Greece,  with  a  small  area  near 
Memel).  We  draw  a  distinction  between  tubercular 
leprosy  and  nerve  leprosy,  according  to  the  localization 
of  the  causative  agents  of  the  disease — viz.,  the  lepra 
bacilli  discovered  by  Hansen  and  Neisser — whether  in 
the  skin  or  in  the  nervous  system.  Not  infrequently 
"mixed  forms"  also  occur. 

In  tubercular  leprosy,  along  with  the  symptoms  of 
a  general  infective  process — fever  and  prodromal  ex- 
anthemata— nodules  and  infiltrated  areas  of  varying 
size  gradually  form,  over  which  the  skin  is  usually 
brown  and  shiny  (Fig.  50),  or  sometimes  may  present 
an  eczematous  or  psoriasiform  appearance.  The  com- 
monest localization  (Fig.  51)— viz.,  on  the  face— pro- 
duces the  early  falling  of  the  eyebrows  and  thickening 
of  the  facial  folds,  which  go  to  make  up  the  so-called 

47 


Jacobi's  Uermochromes. 


Plate  XXVIII. 


<C 


Jacobi's  Dermochromes. 


Plate  XXIX. 


a 

c/) 

O 

3 


Q- 


d 
2 


fades  leontina  (Fig.  52).  The  nodules  may  be  absorbed 
after  long  existence,  or  may  form  indolent  ulcers,  heal- 
ing with  great  difficulty  (Fig.  53),  common  on  the 
mucous  membranes,  which  are  frequently  involved.  It 
seems  that  the  mucous  membranes  are  often  the 
starting-point  of  the  skin  disease ;  at  least,  it  is  stated 
in  many  quarters  that  the  primary  lesion  exists  most 
frequently  in  the  nostril. 

If  the  disease  is  of  long  duration,  the  peripheral 
nerves  generally  are  involved,  and,  finally,  the  internal 
organs  also.  After  illness  extending  over  years,  death 
occurs,  but  previously  blindness  often  results  from  de- 
struction of  the  cornea  or  of  the  entire  eyeball. 

In  nerve  leprosy  the  morbid  changes  are  referable  to 
primary  disease  of  the  peripheral  nerves.  Hyper- 
aesthesia,  anaesthesia,  and  paraesthesiae  may  generally 
be  observed  in  the  earlier  stages.  The  nerve  strands 
which  lie  close  beneath  the  skin  appear  thickened  like 
cords.  At  the  same  time  there  are  changes  in  pigment 
distribution,  sometimes  corresponding  to  the  irreg- 
ularly distributed  anaesthetic  areas,  sometimes  inde- 
pendently, while  atrophies  and  paralyses  of  muscles 
occur,  especially  in  the  face  and  hands — the  so-called 
"clawed  hand"  (Fig.  55). 

Frequently  ulcers  form  as  the  result  of  trophic  dis- 
turbances or  of  injuries  and  burns,  which  are  not  per- 
ceived owing  to  anaesthesia  {e.g.,  "perforating  ulcers," 
Fig.  54),  and  more  extensive  destruction  of  the  skin 
may  give  rise  to  mutilation  and  amputations  of  fingers 
and  toes. 

Although  the  course  of  tubercular  leprosy  is  very 
chronic,  and,  on  the  average,  lasts  from  eight  to  ten 
years  before  death  ensues,  that  of  pure  nerve  leprosy 
and  of  the  mixed  forms  is  even  much  slower.  In  such 
cases  a  duration  of  twenty  to  forty  years  is  not  very 
exceptional. 

48 


In  fully  developed  tubercular  leprosy  the  Diag"- 
nosis  is  not  difficult,  and  may  be  confirmed  by  micro- 
scopical demonstration  of  the  bacilli;  the  history  of 
residence  in  the  tropics  or  in  a  leprous  district  is  to 
be  taken  into  consideration.  On  the  other  hand,  the 
diagnosis  of  nerve  leprosy  is  not  easy,  especially  from 
certain  diseases  of  the  spinal  cord ;  the  swelling  of  the 
peripheral  nerves  is  of  diagnostic  importance.  In  the 
mixed  forms  all  these  points  must  be  considered. 

The  Prognosis  is  absolutely  unfavourable. 

Treatment  has  hitherto  yielded  no  uniformly 
favourable  results.  Salicylate  of  soda,  Chaulmoogra 
oil,  with  baths  and  regular  hygienic  measures  applied 
to  the  skin,  must  be  tried.  The  most  important  measure 
is  prophylaxis  by  the  segregation  of  lepers,  which  has 
enormously  reduced  the  frequency  of  the  disease  in 
Norway,  and  has  been  introduced  into  Germany  in  a 
modified  degree. 


Fig.  50.  Model  in  Lassar's  Clinic,  Berlin  (Kasten). 

Fig.  51.  Model  in  Neisser's  Clinic,  Breslau  (Kroner). 

Fig.  52.  Model  in  the  Saint  Louis  Hospital,  Paris,  No.  1000 
(Baretta).    Leper  from  the  Isle  of  Bourbon. 

Fig.  53.  Model  in  the  Saint  Louis  Hospital,  Paris,  No.  1217 
(Baretta).     Vidal.     Leper  from  Calcutta. 

Figs.  54,  55.  Models  in  Neisser's  Clinic  in  Breslau  (Kroner). 
The  daughter  of  a  fisherman  from  the  neighbour- 
hood of  Memel,  aged  seventeen,  with  disturbances 
of  sensibility ;  wasting,  especially  of  the  arras  and 
legs,  noticed  for  a  year  and  a  half;  pigmentary 
and  blanched  areas  on  the  trunk;  atrophy  of  the 
hands,  especially  of  the  thenar,  hypothenar,  and 
interosseous  muscles. 


49 


Jacobi's  Denuochromes. 


Plate  XXX. 


03 

u 

(U 

■i-f 
tn 

(U 

05 

C 

n 
a. 


d 


13 
V 

a, 

C 


c 


u 

d 


[acobi's  Derinochromes 


Plate  XXXI. 


(Ringworm.) 
No.   56.   Trichophytia  annularis.  No.   57.    Trichophytia  profunda. 


Trichophytia.     Ringworm. 

Plates  XXXI.-XXXIV.,  Figs.  56-63. 

Under  the  name  of  Trichophytia  {Anglice,  "ring- 
worm") are  included  a  number  of  diseases  due  to  the 
presence  in  the  horny  structures  of  the  skin  (epider- 
mis, hair,  nails),  or  sometimes  in  the  deeper  layers,  of 
Hyphomycetes.  The  imity  of  species  of  these  hypho- 
mycetic  fungi  was  formerly  unanimously  accepted,  but 
cannot  now  be  maintained.  There  is  at  least  one 
fungus,  the  cause  of  Gruby's  disease  {Mikrosporia, 
" small-spored  ringworm"),  which  is  definitely  char- 
acterized clinically,  and  must  be  carefully  differenti- 
ated from  other  trichophyta  according  to  Sabouraud's 
researches.  In  Germany  this  disease  may  be  said  not 
to  exist,  but  in  England  and  France  it  forms  the  great 
majority  of  all  cases  of  ringworm.  The  affected  indi- 
viduals are  almost  exclusively  children  under  fifteen 
years  of  age.  The  seat  of  the  disease  is  generally  the 
scalp,  where  more  or  less  numerous,  round  or  oval 
patches  are  present,  over  which  the  hair  is  broken  and 
stumpy,  the  scalp  itself  being  covered  with  white  or 
grayish,  firmly  adherent  scales,  here  and  there  pierced 
by  hairs  (Fig.  58).  Inflammatory  phenomena  are  very 
slight,  and  may  apparently  be  absent.  This  very  ob- 
stinate complaint  usually  recovers  spontaneously  when 
the  patient  attains  the  age  of  fifteen  years. 

The  principal   seat   of   Trichophytia,   properly   so 

50 


called,  is  the  outer  layer  of  the  skin.    Here  there  occur 
circular  areas,   accompanied  by  considerable  inflam- 
matory phenomena,  and  generally  with  marked  itching, 
which  display  either  a  ring  of  vesicles  at  the  margin- 
giving  rise  to  the  unfortunate  name  of  Herpes  some- 
times applied  to  them — or  desquamating,  scaly  patches, 
which  spread  centrifugally    {Trichophytia  annularis, 
Fig.  56).    While  the  process  retrogrades  in  the  centre, 
it  extends  at  the  periphery  and  forms  serpiginous  fig- 
ures by  the  confluence  of  neighbouring  circles.    While 
the  disease  progresses  recrudescences  may  occur  in  the 
centre  of  the  patches,  so  that  beautiful  concentric  rings 
may  be  formed  {Tricliophytia  iris,  Fig.  56).    Most  fre- 
quently the  face,  neck  and  hands  are  attacked,  but  the 
disease  may  be  situated  upon  any  other  portion  of  the 
body.    On  the  scalp  and  in  the  beard  the  appearances 
are  identical,  but  bald,  tonsure-like  spots  result  from 
fracture  of  the  hairs  close  to  their  roots.     Owing  to 
irritative,  eczematous  changes,  the  disease  described  as 
Eczema  marginatum  may  result. 

While  these  phenomena  are  due  to  the  presence  of 
the  fungus  in  the  upper  epidermic  layers,  its  migration 
into  the  hair-follicles  of  the  scalp  or  beard  causes  much 
more  severe  changes.  In  the  conditions  denominated 
Trichophytia  profunda  (Fig.  57),  Sycosis  parasitaria 
(Fig.  62),  and  Kerion  Celsi  (Fig.  59),  which  almost 
exclusively  affect  hairy  parts,  hard,  firm,  irregulai 
lumps  and  nodules  form,  or  even  dense  infiltrations 
and  abscesses  (Fig.  61),  penetrated  by  dilated  hair- 
follicles,  and  may  exhibit  a  peculiar  scar-like  appear- 
ance; these  sometimes  attain  considerable  dimensions. 
Finally,  the  hairs  disappear  by  destruction  of  the  fol- 
licles, and  the  affection  heals  very  slowly,  generally 
with  the  formation  of  scars. 

We  have  to  consider  as  a  last  form  of  Trichophytia 
of  the  skin  a  disease  produced  by  an  acute  invasion  of 

51 


Jacobi's  Dermochromes. 


Plate  XXXII. 


(Ringworm.) 
No.   58.   Trichophytia  capillitii  No.  59.  Trichophytia  profunda  capillitii 

(Mikrosporia).  Kerion  Celsi). 


No.  60.  Trichophytia  unguium  (Ringworm). 


Jacobi's  Derinochromes. 


Plate  XXXIII 


Q 

T. 

V 


?    2 

CD 


H 
2, 


fungus  over  large  tracts  of  skin.  This  form  may  either 
begin  as  a  solitary  trichophytic  disc  {Medaillon  pri- 
maire,  Herald  patch),  which  may  exist  for  a  long 
time,  or  may  develop  without  it.  From  numerous 
pale-red  little  papules  round,  or  more  generally  oval, 
discs  form,  some  as  large  as  a  shilling,  which  coalesce 
very  freely,  and  exhibit  centrifugal  desquamation  at 
the  margin.  The  process  is  extremely  superficial,  and 
spontaneous  recovery  usually  occurs  in  the  course  of 
some  weeks.  This  disease  is  termed  Herpes  tonsurans 
maculosus,  and  is  identical  with  the  Pityriasis  rosea  of 
Gibert.  Its  favourite  seats  are  the  neighbourhood  of 
the  neck,  the  chest,  and  back ;  less  frequently  the  abdo- 
men and  limbs  are  aifected  (Fig.  63).* 

Invasion  of  the  nails  may  show  itself  under  different 
aspects.  The  substance  of  the  nails  is  rendered  opaque, 
becomes  brittle  and  of  brownish  colour,  and  their  shape 
is  altered,  with  formation  of  furrows,  ridges,  etc.  At 
the  margins  they  easily  shell  off  (Fig.  60). 

The  Diag'nosis  of  the  various  forms  of  ringworm 
offers  no  difficulty  when  the  fungus  can  be  micro- 
scopically demonstrated,  either  by  staining  or  after 
mere  soaking  in  liquor  potassse.  The  mycelia  appear 
under  the  microscope  as  bright,  segmented  and  dicho- 
tomous  figures,  with  double  contours.  Culture  experi- 
ments may  also  be  employed  for  confirming  the  diag- 
nosis. As,  however,  the  existence  of  the  fungus  cannot 
always  be  demonstrated  in  all  stages,  other  points 

*  Professor  Jacobi  follows  the  custom  prevalent  in  Germany 
and  Austria  of  considering  pityriasis  rosea  a  form  of  ringworm. 
He  informs  me  that  he  has  succeeded  in  staining  a  fungus  by 
Boeck's  method  in  one  case ;  the  fact  is,  as  far  as  I  am  aware,  an 
isolated  one.  Xumerous  observers  in  France  and  Great  Britain — 
among  whom  I  may  include  myself — have  failed  to  find  any 
trace  of  trichophyton  or  other  fungus,  and  are  agreed  in  think- 
ing that  this  curious  disease  is  in  no  way  connected  with  ring- 
worm. The  differential  diagnosis  of  the  two  diseases  is,  indeed, 
of  the  highest  practical  importance. — J.  J.  Pringle. 

52 


worthy  of  observation  are:  the  localization,  the  circu- 
lar form,  the  superficial  situation,  and  the  centrifugal 
desquamation  at  the  margin  of  the  patches.  The 
tonsure-like  spots  over  which  the  hairs  are  broken  off, 
and  the  dusky  appearance  of  the  diseased  hairs,  espe- 
cially after  treatment  with  chloroform,  may  be  con- 
sidered as  diagnostic  in  the  scalp  and  beard. 

As  regards  Differential  Diag-nosis,  psoriasis 
must  first  be  considered.  In  psoriasis  the  scales  are 
larger,  more  brilliant,  and,  as  a  rule,  punctiform 
haemorrhages  occur  after  their  removal  with  the  nail, 
while  psoriasis  generally  itches  less  than  ringworm. 
Certain  forms  of  eczema  may  exhibit  similar  outlines, 
but  they  are  seldom  so  definite;  the  discharge  from 
an  eczema  may  also  facilitate  the  diagnosis.  Syphi- 
lides  show  deeper  infiltration,  and  are  of  darker  colour. 
Lupus  erythematosus  may  be  distinguished  by  the 
invasion  of  the  sebaceous  follicles,  as  well  as  by  the 
cicatricial  atrophy  in  the  centre.  Parasitic  sycosis  of 
the  beard  is  to  be  differentiated  from  the  non-parasitic 
form  chiefly  by  the  greater  amount  of  infiltration  and 
its  deeper  localization.  In  its  earliest  stages  favus 
may  sometimes  present  very  similar  appearances  to 
ringworm,  but  after  a  certain  time  scutula  always  form. 
On  the  scalp  the  two  maladies  are  often  very  difficult  to 
distinguish,  especially  if  favus  has  been  previously 
treated,  but  the  point  is  not  one  of  very  great  practical 
importance.  It  is  important  to  bear  in  mind  that  in 
favus  the  fungus  usually  is  present  in  considerably 
greater  abundance  than  in  ringworm. 

The  Prog'nosis  is  generally  favourable,  but  the 
disease  in  the  beard  and  on  the  scalp  is  particularly 
obstinate. 

53 


Jacobi's  Dermocliroines. 


,  Plate  XXXIV. 


w 

c 


o 


>^ 


6 


Treatment. — Cure  can  easily  be  obtained,  when 
the  disease  affects  merely  the  epidermis  of  glabrous 
parts,  by  means  of  bactericidal  substances,  or  such  as 
produce  vigorous  separation  of  the  epidermis.  Thus, 
tincture  of  iodine,  the  inunction  of  sulphur  soap,  or  of 
Kaposi's  naphthol  ointment,  attain  this  object  without 
difficulty  in  the  vesicular  and  squamous  varieties,  and 
the  latter  is  efficacious  in  pityriasis  rosea,  which  also 
yields  easily  to  treatment  with  pastes  or  powders. 
The  principal  anti-mycotic  remedies  in  use  are  chrysa- 
robin,  pyrogallol,  or  a  1  per  cent,  solution  of  corrosive 
sublimate  in  tincture  of  benzoin.  Tar,  either  pure  or 
in  the  form  of  Wilkinson's  ointment,  acts  very  usefully. 
The  treatment  of  the  deep-lying  ringworms  is  much 
more  difficult ;  in  them  poultices  may  be  recommended, 
followed  by  compresses  of  a  1  per  cent,  solution  of 
acetate  of  aluminium  or  resorcin.  In  later  stages 
chrysarobin,  Brooke's  paste,  or  corrosive  sublimate, 
may  prove  of  good  service.  Epilation  must  always  be 
practised,  and  must  be  a  preliminary  to  the  treatment 
of  ringworm  of  the  scalp;  afterward  inunction  of 
chrysarobin,  painting  with  tars,  solutions  of  corrosive 
sublimate  or  tincture  of  iodine,  ointments  of  sulphur 
or  croton  oil,  may  all  be  tried.  Lastly,  "Light  treat- 
ment" may  effect  a  cure,  although  often  only  after  a 
very  long  time. 


Fig.  56.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 
Figs.  57,  59,  62.  Models     in     Neisser's     Clinic     in     I?reslau 

(Kroner). 
Fig.  58.  Model  by  Professor  Jacobi  in  the  Freiburg  Clinic. 
Fig.  60.  Model  in  Lassar's  Clinic  in  Berlin  (Kasten). 
Fig.  61.  Model  in  Saint  Louis  Hospital  in  Paris,  No.   1051 

(Baretta).     Vidal's  case. 
Fig.  63.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 


54 


Erythrasma. 

Plate  XXXIV.,  Fig  64. 

Erythrasma  shows  itself  as  accurately  marginated 
patches  of  brown  or  brownish-red  colour,  with  convex 
outlines  and  finely  desquamative  surface,  the  per- 
ipheral portions  of  which  are  slightly  reddened.  They 
occur  principally  on  the  inner  sides  of  the  thighs  close 
to  the  genitals,  on  the  scrotum,  labia  majora  and 
perinaeum,  and  on  the  adjacent  portion  of  the  abdomen ; 
they  may  also  attack  the  armpits  and  thence  spread 
to  the  chest  and  trunk.  It  is  caused  by  a  mycelium, 
the  Microsporon  minutissimum,  and  it  is  always  very 
superficially  situated  in  the  epidermis.  The  disease  is 
obstinate,  although  absolutely  harmless. 

The  Diagnosis  is  easily  made  on  the  grounds  of 
its  localization,  colour  and  fine  desquamation. 

The  Treatment  is  similar  to  that  of  the  super- 
ficial forms  of  ringworm. 


Fig.  64.  Model  in  Riehl's  Clmic  in  Vienna  (Henning). 


55 


I 


Jacobi's  Dennochromcs. 


FUte  XXXV, 


Xo.  65.  Pityriasis  versicolor. 


Pityriasis  Versicolor. 

Plate  XXXV.,  Fig.  65. 

Pityriasis  versicolor  occurs  more  especially  in  per- 
sons who  sweat  freely,  and  therefore  very  frequently 
in  the  phthisical.  It  shows  itself  as  small  yellow  or 
brownish  spots,  which  sometimes  are  arranged  in  con- 
fluent patches,  and  are  caused  by  the  invasion  of  the 
epidermis  by  the  Microsporon  furfur.  The  individual 
spots  are  very  superficial,  only  slightly  elevated,  and 
rarely  somewhat  reddened  at  the  edge.  The  branny 
desquamation  is  most  marked  when  the  spots  are 
lightly  rubbed;  there  is  never  coarse  scaling.  If  the 
part  is  scratched,  the  entire  diseased  corneal  layer  is 
removed  in  the  form  of  a  thin  pellicle,  and  the  nearly 
normal  subjacent  skin  is  exposed.  The  disease  chiefly 
affects  the  trunk,  whence  it  sometimes  spreads  over 
the  limbs  and  neck ;  the  face,  palms  and  soles  are,  how- 
ever, always  free. 

Subjective  symptoms  are,  as  a  rule,  completely 
absent,  so  that  the  malady  is  often  unnoticed. 

The  Diagnosis  can  be  made  with  facility  from 
the  yellow  colour  and  localization  of  the  disease,  and 
by  the  possibility  of  removing  the  spots  by  scratching. 
It  can  be  confirmed  by  the  detection  under  the  micro- 
scope of  the  network  of  mycelium  and  numerous 
clumps  of  brightly  refractive  spores. 

56 


The  Prog-nosis  is  favourable. 

Treatment  easily  produces  temporary  favour- 
able results,  but  a  permanent  cure  is  obtained  only 
with  difficulty.  All  antimycotic  remedies  may  be  used 
with  benefit,  as  may  inunctions  of  sulphur  soap,  paint- 
ing with  alkaline  spirit  of  soap,  sometimes  with  the 
addition  of  1  per  cent,  of  naphthol ;  or  baths  followed 
by  lotions  of  corrosive  sublimate,  naphthol,  etc.,  may 
be  used.  The  best  results  we  have  obtained  have  been 
with  the  treatment  recommended  by  Besnier,  consist- 
ing of  the  alternate  inunction  of  salves  containing  1  to  3 
per  cent,  of  resorcin  and  salicylic  acid,  and  5  to  15 
per  cent,  of  sulphur. 


Fig.  65.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 


57 


'I 


Jacobi's  Dermochronies. 


Plate  XXXV : 


en 

(U 

Ch 

I. 

<u 
u 

3 

P 
o 
tn 

U3 

3 
> 

oi 

Uh 

t^ 

d 
2 


3 


6 
2 


I! 


Favus. 

Plate  XXXVI.,  Figs.  66  and  67. 

Favus  is  most  commonly  present  on  the  scalp  in 
children,  and  is  characterized  by  the  formation  of  so- 
called  "favTis  cups"  (or  scutula);  these  are  saucer- 
like,  yellow  or  sulphur  coloured,  hollowed  discs,  which 
are  composed  of  thickly  welded  masses  of  Achorion 
Schonleinei — the  causative  fungus  of  the  disease — 
mixed  with  detritus  and  epithelium,  covered  with  a 
thin  coat  of  the  horny  layer,  and  perforated  in  the 
centre  by  a  hair  (Fig.  66).  After  the  scutulum  is 
removed,  a  shallow  depression  is  perceptible,  which,  as 
the  result  of  the  exposure  of  the  rete  Malpighii,  is 
moist  and  glistening.  After  some  time  has  elapsed 
the  favus  cups  coalesce  to  form  whitish,  mortar-like 
masses  (Favus  confertus),  which  in  some  cases  involve 
the  greater  part  of  the  scalp,  and  only  show  the  mode 
of  formation  of  the  composite  patches  by  some  scat- 
tered cups  at  their  margin.  Over  the  affected  areas  the 
hairs  are  lustreless,  as  if  powdered,  and  the  disease 
exhales  a  musty,  mouse-like  odour.  Its  course  on  the 
scalp  is  extremely  chronic,  and  in  the  majority  of 
cases,  terminates  in  cicatricial  atrophy,  as  the  result  of 
pressure  by  the  fa^'us  cups,  with  permanent  alopecia 
of  the  affected  parts. 

The  affection  occurs  more  frequently  on  the  scalp 
than  on  the  body,  where  circles  first  appear,  either 

58 


covered  with  scales,  or  showing  vesicles  at  their  mar- 
gin, and  these  exactly  resemble  the  lesions  produced 
by  trichophytia ;  only  after  protracted  duration  do  they 
exhibit  one  or  more  seutula  in  the  centre  (Fig.  67).  On 
the  skin  of  the  body  the  disease  is  not  at  all  obstinate, 
and  recovers  without  leaving  any  marks. 

In  rare  cases  the  favus  fungus  may  penetrate  deeply, 
and  evoke  a  condition  analogous  to  kerion.  The  nails 
may  also  suffer  in  the  same  way  as  in  ringworm; 
occasionally  cup-like  lesions  are  found  embedded  in  the 
nail  substance. 

Recent  investigations  have  proved,  contrary  to  the 
views  of  Quincke,  Unna  and  others,  that  favus  is  in 
all  probability  caused  l)y  one  form  of  fungus  only, 
which  may  assume  different  developmental  forms  on 
different  media.  Animals  {e.g.,  cats  and  mice),  which 
are  susceptible  to  invasion  by  favus,  are  often  the 
starting-point  of  the  disease  in  man. 

The  Diag'nosis  is  generally  easy  in  presence  of 
the  favus  cups,  which  become  of  an  intense  yellow  hue 
when  moistened  with  alcohol,  or  after  microscopical 
demonstration  of  the  fungus.  The  powdery  appear- 
ance of  the  hairs  and  the  musty  odour  are  also  points 
of  importance.  Even  after  favus  has  terminated,  the 
cicatricial  atrophy  of  the  scalp  may  establish  a  retro- 
spective diagnosis. 

The  Prog^iiosis  is  favourable  on  the  body,  but 
on  the  scalp  it  must  be  very  guarded,  as  permanent 
alopecia  is  usually  the  ultimate  result  of  the  disease. 

Treatment  has  for  its  first  object  the  removal 
of  the  seutula,  which  may  be  effected  by  an  oil-cap; 
then  energetic  epilation  must  be  instituted,  and  in  very 
extensive  cases  this  may  be  done  by  the  application 

59 


Jacobi's  Dermochromes. 


Flate  XXXVU. 


No.  68.   Psoriasis  vulgaris  guttata  et  ostracea. 


No.   69.    Psoriasis  vulgaris. 


of  the  calotte  under  an  anaesthetic.  Afterward  regular 
washing  with  soap  and  the  subsequent  use  of  ehrysaro- 
bin,  tincture  of  iodine,  sublimate  spirit  or  ointment, 
or  naphthol  may  be  recommended.  Tar,  ichthyol,  and 
tumenol  are  used  with  good  success.  Treatment  by 
X-rays  appears  to  yield  excellent  results,  but  must 
be  employed  with  the  greatest  caution  on  account  of 
the  risk  of  X-ray  burns. 


Fig.  66.  Model  in  Saint  Louis  Hospital,  Paris,  No.  548  (Bar- 

etta).    Besnier. 
Fig.  67.  Model  in  Neisser's  Clinic  in  Breslau  (Kroner). 


60 


Psoriasis  Vulgaris. 

Plates  XXXVII.-XLI.,  Figs.  68-76. 

By  Psoriasis  we  understand  a  chronic,  nearly  always 
incurable,  disease  of  the  skin,  the  cause  of  which  is 
unknown — but  is  very  probably  of  fungous  origin — and 
in  which  relapsing  outbreaks  of  eruption  alternate 
with  intervals  of  more  or  less  freedom.  The  primary 
lesions  are  typical  and  consist  of  small  points,  the 
size  of  a  pin's  head,  which  soon  become  covered  with 
firmly  adherent  scales.  As  they  develop  and  spread, 
all  the  different  forms  of  Psoriasis  guttata  (Fig.  68), 
nummularis,  etc.,  arise;  when  healing  occurs  in  the 
centre,  Psoriasis  annularis  results,  and  when  neigh- 
bouring circular  patches  run  together  the  condition 
is  called  Psoriasis  gyrata  vel  figurata  (Fig.  70).  The 
localization,  chiefly  on  the  extensor  sides  of  the  ex- 
tremities and  on  the  scalp  (Fig.  71),  is  characteristic 
of  psoriasis,  as  is  the  production  of  small,  punctiform, 
bleeding  points  in  the  exposed,  moist,  red  and  shiny 
rete  Malpighii,  after  the  scales  are  rubbed  off.  Lastly, 
the  absence  of  any  dense  infiltration  is  typical,  in  con- 
tradistinction to  other  similar  diseases,  especially 
scaly  syphilides.  Deviations  from  the  general  rule  as 
to  distribution  occur,  however,  not  infrequently  and 
there  is  no  part  of  the  skin  which  may  not  occasionally 
be  the  seat  of  the  eruption  (Fig.  75).  Even  on  the 
palms  and  soles  psoriasis  may  exist,  not  only  in  uni- 
versal attacks,  but  also  in  localized  cases,  so  that  it 

61 


I 


Jacobi's  Dermochromes. 


Plate  XXXVIII. 


mgM^Bm 


V*T"' 


XT^ 


■:^r'\^;■■    ^  •y'Tf -r. 


^ 


'.'-i 


'\ 


No.   ;o.    Psoriasis  gyrata  et  serpiginosa. 


lacobi's  Dermochromes. 


Plate  XXXIX. 


3 


> 


t/i 

o 

t/3 


r4 
6 

2 


Oh 


> 

'55 

O 
t/1 


o 

2 


is  highly  desirable  to  discontinue  the  use  of  the  name 
Psoriasis  palmaris  et  plantaris  as  designating  papulo- 
squamous syphilides  of  the  palms  and  soles  (Fig.  76). 
Mucous  membranes  are  hardly  ever  involved  in  psori- 
asis. The  so-called  Psoriasis  Tmicosoe  oris  has  no 
relationship  to  true  psoriasis,  and  is  better  named 
Leucoplakia. 

Very  marked  changes  may  be  observed  in  the  ex- 
tremely chronic  course  of  psoriasis  without  any  treat- 
ment, a  circumstance  which  greatly  prejudices  our 
judgment  as  to  the  value  of  all  therapeutic  measures. 
Frequently  eczematous  complications  occur.  Consid- 
erable differences  may  be  observed  not  only  in  the 
shape  and  size,  but  also  in  other  attributes  of  the 
psoriatic  lesions;  thus  the  characters  and  thickness 
of  the  scales  vary  greatly,  and  thick  mortar-like  or 
oyster-shell-like  masses  may  be  present  side  by  side 
with  comparatively  thin  scales;  while  all  shades  of 
colour  may  coexist,  from  a  pure  glistening  mother-of- 
pearl  white  to  a  dark,  grayish-yellow  or  gray  tint 
(Figs.  68,  69,  74).  In  the  same  way  the  intensity  and 
width  of  the  red  band  which  bounds  the  scales  vary; 
sometimes  it  is  of  a  yellow  rather  than  a  red  colour, 
while  on  dependent  parts  a  more  livid  tint  may  pre- 
dominate. 

The  seats  of  predilection  are,  as  already  stated,  the 
backs  of  the  elbows,  fronts  of  the  knees  and  the  scalp, 
but  in  other  cases  the  disease  is  much  more  widely 
distributed  and  may  involve  the  greater  part  of  the 
integument.  In  acute  cases  scarcely  any  region  may 
remain  unaffected  (Fig.  75),  and  in  these  circum- 
stances severe  general  symptoms  may  develop,  whereas 
in  localized  cases  the  general  health  is  unaltered.  It 
is  a  generally  recognised  fact  that  psoriatics  are  fre- 
quently robust,  well-nourished  individuals.  In  the 
chronic  forms  trifling  itching  is,  as  a  rule,  the  only 

62 


subjective  symptom  present,  but  in  acute  and  extensive 
outbreaks  a  troublesome  feeling  of  thirst  is  often  com- 
plained of. 

When  psoriasis  is  localized  on  the  hands  and  feet 
there  occur,  besides  other  changes  in  the  nails,  marked 
thickening  of  the  nail  substance,  with  opacity  and  sep- 
aration from  the  nail-bed,  which  begins  at  the  per- 
ipheral end  (Figs.  72,  73).  In  severe  cases  the  nails 
may  even  be  completely  shed. 

The  Pz*Og'ilosis  is  so  far  favourable  that  only  in 
exceptional  cases  is  there  any  deterioration  in  the  gen- 
eral health,  and  individual  eruptions  can  be  cured.  A 
definite,  final  cure  of  psoriasis  is,  however,  impossible. 

Differential  Diagnosis.— Syi^hilis,  eczema 
seborrhoicum,  lupus  erythematosus,  true  eczema  and 
ringworm  must  first  be  considered. 

Ringworm  may  be  eliminated  by  the  absence  of 
fungus  and  its  acuter  evolution.  In  contradistinction 
to  lupus  erythematosus,  psoriasis  never  leaves  scars, 
and  does  not  invade  sebaceous  follicles.  Eczema  sebor- 
rhoicum corporis  {Lichen  cirmonscriptus  of  Villan) 
generally  displays  smaller  and  more  fatty  scales  with 
brighter  yellowish-red  coloration,  and  its  typical  dis- 
tribution is  on  the  chest  and  back.  The  differentiation 
from  simple  eczema  is  more  difficult,  chiefly  because 
combinations  of  the  two  maladies  occur.  As  a  rule  the 
localization  and  the  fact  that  true  psoriasis  never 
weeps,  as  well  as  the  determination  of  the  elementary 
lesions  of  either  disease,  suffice  to  establish  a  diagnosis. 
Syphilis  attacks  most  frequently  flexor  surfaces,  and 
its  papulo-squamous  lesions — which  only  need  to  be 
considered  here — are  accompanied  by  dense  infiltra- 
tion. In  syphilis,  too,  itching  is  absent,  but  in  dubious 
cases  the  effects  of  treatment  will  be  decisive. 

63 


Jacobi's  Deriiiochronies. 


Plate  XL. 


No.    'J2,-   Psoriasis  vulgaris  unguium. 


No,    74.   Psoriasis   vulgaris  rupioides. 


[I  Jacobi's  Dertnochromes. 


Plate  XLI. 


No.   75,    76.    Psoriasis  vulgaris. 


Treatment  may  be  either  by  internal  or  ex- 
ternal means.  The  most  important  internal  remedy 
is  arsenic,  which,  if  properly  employed,  almost  always 
brings  about  the  recovery  of  psoriasis  spots,  but  with 
deep  pigmentation.  It  may  be  used  in  the  form  of 
"Asiatic  pills,"  or  of  subcutaneous  or  intramuscular 
injections  of  the  liquor  sodii  arseniatis.  Iodine  is  not 
so  certain  a  remedy,  but  is  efficacious  in  a  number  of 
cases,  provided  it  is  prescribed  in  the  form  of  iodide  of 
potassium  and  in  full  doses.  Other  drugs  (thyroid 
gland,  etc.)  have  been  proved  to  be  uncertain  in  action 
or  quite  futile. 

The  first  object  of  external  treatment  is  the  removal, 
after  maceration,  of  the  scaly  masses.  Baths,  soaping 
and  washing,  salicylic  ointment  and  super-fatty  soaps, 
alcohol  sprays  or  compresses,  with  frequent  ablutions, 
soon  produce  the  desired  effect.  Reducing  and  slightly 
irritating  remedies  must  be  applied  after  the  removal 
of  the  scales.  Chrysarobin  stands  in  the  first  rank,  and 
may  be  used  in  the  form  of  weak  ointments  (2  to  5 
per  cent.)  once  or  twice  daily  until  slight  irritation  of 
the  skin  is  caused.  The  effect  of  chrysarobin  seems  to 
depend  on  the  variable  quality  of  the  drug.  Only  those 
preparations  which  produce,  after  protracted  applica- 
tion, a  dermatitis,  will  be  found  of  importance  in  the 
treatment  ,of  psoriasis.  As  the  drug  varies  greatly 
in  quality  and  consequent  effect,  it  is  well  to  use  only 
preparations  which,  after  prolonged  use,  cause  some 
degree  of  dermatitis.  Chrysarobin  ought  not  to  be 
used  for  the  face  and  scalp,  on  account  of  the  ugly 
discoloration  of  the  skin  and  hair  it  produces,  as  well 
as  of  its  irritating  effect  on  the  conjunctiva.  If  chry- 
sarobin irritation  sets  in,  or  even  threatens  to  do  so, 
the  remedy  must  be  at  once  discontinued  and  treatment 
by  indifferent  soothing  ointments,  pastes  or  tars  sub- 
stituted.   Chrysarobin  stains  the  normal  skin  a  dark- 

CA 


bluish  or  brownish-red  colour,  in  the  midst  of  which 
the  diseased  parts  appear  pale,  and  chrysarobin  stain- 
ing only  disappears  when  recovery  is  complete.  The 
drug  may  be  applied  to  localized  spots  dissolved  in 
chloroform  (10  per  cent.),  traumaticin  being  afterward 
painted  over  them. 

Pyrogallol  produces  similar,  but  not  such  satisfac- 
tory, results ;  it  may  be  employed  in  the  form  of  a  5  per 
cent,  ointment,  but  ought  never  to  be  used  over  more 
than  one-fifth  of  the  surface  of  the  body  at  a  time,  on 
account  of  the  risk  of  poisoning. 

Tar  is  employed,  principally  in  the  form  of  tar  baths, 
tar  oil  or  tincture  of  tar,  and  is  specially  recommended 
for  psoriasis  of  the  scalp.  Similar  but  milder  in  its 
action  is  the  liquor  carbonis  detergens,  which  is  ap- 
plicable to  uncovered  parts,  owing  to  its  slight  smell 
and  colourlessness.  A  10  per  cent,  white  precipitate 
ointment,  to  which  10  to  20  per  cent,  of  liquor  carbonis 
may  be  added,  is  in  common  use  for  the  treatment  of 
the  face.  Specially  obstinate  psoriasis  spots  often  dis- 
appear under  eugallol — a  pyrogallol  derivative — which 
is  applied  mixed  with  2  parts  of  acetone,  and  covered 
with  zinc  paste  or  dusting-powder. 

It  can,  however,  only  be  used  for  single  small  patches. 
Eegular  hot  baths  with  sulphur,  ordinary  warm-water 
bathing  or  hot-air  baths,  help  other  treatment;  sea- 
baths  are  often  deleterious.  If  eczema  is  present,  it 
must  first  be  cured  before  the  treatment  of  the  psor- 
iasis is  undertaken.  Radium,  uviol  and  X-rays  are  also 
recommended. 

Figs.  68,  71.  Models  in  Neisser's  Clinic  in  Breslau  (Kroner). 
Figs.  69,  72,  73.  74.  Models    in    Neisser's    Clinic,    Breslau 

(Kroner). 
Fig.  70.  Model  in  Lessers  Clinic  in  Berlin  (Kolbow). 
Fig.  75.  Model    in    Saint    Louis    Hospital,    Paris,    No.    1670 

(Baretta).     Du  Castel. 
Fig.  76.  Model  in  Neisser's  Clinic  in  Breslau   (Kroner).     A 

man,  thirty-five  years  of  age,  who,  in  the  nonrse  of 

a    rather   e.xtonsive   eruption,    had    manifestations 

on  the  palms  and  soles. 
65 


'II 


Jacobi's  Deniiochromes. 


Plate  XLII. 


No.    ".    Lichen   planus. 


No.   78.   Lichen   planus  atrophicus. 


Lichen  Planus. 

Plates  XLII.-XLIV.,  Figs.  77-81. 

Under  the  term  Lichen  are  included  those  diseases, 
the  primary  lesion  of  which  is  represented  by  a  small 
papule  which  undergoes  no  further  development. 
Properly  speaking,  therefore,  only  two  affections  come 
into  consideration — viz..  Lichen  ruber  planus,  and 
Lichen  acuminatus.  The  latter  is  a  very  rare  disease, 
first  observed  by  Hebra,  in  which  numerous,  red, 
pointed  papules  occur,  tipped  by  horny  caps,  which 
may  run  together  to  form  rough,  grater-like  patches. 
As  the  disease  spreads  the  nails  are  involved,  the  hair 
falls,  and  the  earliest  described  cases  proved  fatal, 
with  all  the  characteristics  of  a  severe  general  malady. 
It  is  uncertain  whether  this  type  of  disease  still  exists, 
or  whether  its  serious  results  are  now  warded  off  by 
the  arsenical  treatment  introduced  by  Hebra. 

The  great  majority  of  lichen  cases  now  observed  are 
examples  of  Lichen  planus,  the  elementary  lesions  of 
which  consist  of  minute  papules,  sometimes  as  large  as 
a  hempseed,  but  occasionally  larger;  they  are  waxy- 
looking  and  shiny,  and  of  bright-red  colour;  they  are 
generally  smooth  on  the  surface,  accurately  delimi- 
tated and  polygonal,  while  sometimes  they  are  crested 
with  a  firmly  adherent  scale.  When  numerous  papules 
run  together  the  skin  presents  peculiar,  raised  patches. 
Involution  is  accompanied  by  deep  pigmentation,  and 

66 


often  begins  in  the  centre,  while  the  process  spreads 
at  the  margin,  so  that  the  skin  assumes  the  appear- 
ance of  shagreened  leather.  Intense  itching  is  the 
most  prominent  subjective  symptom;  it  gives  rise  to 
scratching  and  thus  to  narrow  linear  bands,  which 
appear  to  be  made  up  of  lichen  papules  in  close  appo- 
sition. Lichen  papules  also  may  exist,  arranged  in 
the  most  diverse  manners,  sometimes  being  in  rings, 
or  in  net-like  patterns,  or  in  circles  (Lichen  annularis, 
Fig.  79).  After  long  duration  a  peculiar  warty  appear- 
ance may  be  assumed,  especially  upon  the  legs  (Lichen 
verrucosus,  Fig.  80).  The  disease,  which  is  a  very 
chronic  one,  generally  occurs  in  successive  outbreaks, 
and  disappears  very  slowly,  sometimes  leaving  atrophy 
of  the  parts  occupied  by  papules  (Lichen  atrophicus, 
Fig.  78).  The  affection  is  frequently  localized  on  the 
flexor  surfaces  of  the  extremities  (Fig.  77),  but  any 
part  of  the  body  may  be  attacked,  even  the  mucous 
membranes  (Fig.  81),  on  which  the  lesions  appear 
as  whitish,  silvery,  glistening  patches  with  thickened 
epithelium.  Their  occurrence  on  the  penis  is  note- 
worthy, either  alone  or  in  conjunction  with  a  general- 
ized eruption.  Very  rarely  lichen  papules  become 
vesicular. 

The  Etiolog'y  of  lichen  is  not  yet  definitely  estab- 
lished, but  many  exciting  causes  of  vegetable  nature 
(fungi)  have  been  assumed  to  exist. 

The  Diagnosis  can  be  made  without  any  diffi- 
culty if  typical  lichen  papules  are  present. 

The  DifiEerential  Diagfi^osis  must  first  be 
made  from  the  small  papular  syphilide — sometimes 
unfortunately  called  Lichen  syphiliticus — which  may, 
however,  be  distinguished  by  the  coppery  colour  char- 

67 


Jacobi's  Dermochromes. 


Plate  XLIII. 


D 
(A 

o 

u 

3 

> 

3 
C 


6 

CO 

d 


t/5 

3 
C 
03 


C 
1) 


6 
Z 


I 


I 


Jacobi's  Dermochromes. 


Plate  XLIV. 


a, 
o 

V 


3 


t/3 

3 


rt 


u 

1-1 


o 


acteristic  of  syphilitic  eruptions,  by  the  absence  of 
itching,  and  by  the  presence  of  concomitant  manifesta- 
tions of  syphilis.  When  large  tracts  of  skin  are  in- 
volved by  lichen,  difficulties  may  arise  as  to  diagnosis 
from  psoriasis;  but  in  the  latter  disease  there  are  no 
typical  lichen  papules  and  none  of  the  scratch-mark 
phenomena  described,  whereas  the  typical,  large, 
mother-of-pearl  lamellar  scales  are  present.  The 
diagnosis  may  be  difficult  when  the  soles  and  palms 
are  involved,  as  lichen  causes  large  callosities  in  these 
situations.  The  primary  lesions  must,  therefore,  be 
looked  for  and  the  existence  of  itching  considered  in 
establishing  a  diagnosis  between  lichen  on  the  one 
hapd  and  ichthyosis  or  psoriasis  on  the  other. 

The  Prog-nosis  is,  on  the  whole,  favourable,  but 
relapses  and  recrudescences  are  not  infrequent  during 
treatment.  Fatal  cases  of  Lichen  acuminatus  of  Hebra 
are  no  longer  observed. 

Treatment. — Most  important  is  the  internal  ad- 
ministration of  arsenic,  either  in  the  form  of  "Asiatic 
pills,"  or  by  subcutaneous  or  intramuscular  injection 
of  the  liquor  sodii  arseniatis;  but  recovery  only  sets 
in  after  comparatively  large  doses  have  been  admin- 
istered. The  first  object  of  external  treatment  is  to 
allay  itching  by  the  use  of  tarry  applications.  Chry- 
sarobin,  pyrogallol,  mercurial  plaster,  or  Unna's  sub- 
limate and  carbolic  acid  plaster-mull,  act  well  in  com- 
bination with  warm  baths.  In  stubborn  cases  light 
treatment  (X-rays  and  ultraviolet  rays)  has  proved 
beneficial. 


Figs.  77,  79.  Models  in  St.  Louis  Hospital  in  Paris,  Nos.  1398, 

1554  (Baretta).    Hallopeau. 
Figs.  78,  80.  Models  in  Neisser's  Clinic  in  Breslau  (Kroner). 
Fig.  81.  Model  in  Lassar's  Clinic  in  Berlin  (Kasten). 

68 


Leucoplakia. 

Plate  XLIV.,  Fig.  82. 

On  the  tongue,  especially  at  the  margins,  on  the 
buccal  mucous  membrane  in  contact  with  the  teeth,  at 
the  angles  of  the  mouth,  and  on  the  mucous  lining  of 
the  lips,  roundish,  often  confluent  patches  are  fre- 
quently present,  especially  in  persons  who  smoke  and 
drink  to  excess,  over  which  the  epithelium  is  thickened 
and  opaque.  They  pursue  an  extremely  chronic  course, 
they  are  slightly,  if  at  all,  raised  and  exhibit  little  or 
no  inflammation  at  the  edge.  In  many  cases  there  is 
a  history  of  antecedent  syphilis,  but  the  affection  can 
certainly  not  be  regarded  as  specific,  inasmuch  as  it 
also  occurs  in  non-syphilitic  subjects,  and  is  absolutely 
uninfluenced  by  anti-syphilitic  treatment.  Epithe- 
lioma may  develop  on  leucoplakial  patches  as  the  re- 
stilt  of  long-continued  irritation.  There  is  usually  very 
little  pain. 

The  Diag'nosis  is  easy  in  typical  cases,  as  the 
long  duration,  the  localization  and  the  absence  of  in- 
flammatory phenomena  permit  of  easy  distinction  from 
syphilitic  plaques.  Lichen  planus  of  the  mucous  mem- 
brane of  the  mouth  is  always  accompanied  by  lichen 
elsewhere.  The  "geographical  tongue"  is  congenital, 
and  soon  alters  in  character. 

C9 


The  Prognosis  is,  on  the  whole,  favourable,  ex- 
cept in  the  rare  cases  in  which  carcinoma  develops  on 
a  leucoplakial  basis. 

Treatment  can  only  be  followed  by  good  results 
in  the  early  stages.  Apart  from  local  treatment  by 
chromic  and  lactic  acids,  papayotin  or  salicylic  alcohol, 
lotions  of  decoction  of  bilberry  are  recommended. 
Obviously,  smoking  and  indulgence  in  alcohol  must  be 
interdicted. 


Fig.  83.  Model  in  Saint  Louis  Hospital  in  Paris,  No.  1573 
(Baretta).    Fournier. 


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